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of  ^fjpgitians  anb  burgeons 
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TEXT-BOOK     ON 
S  U  K  G  E  E  Y 

GENERAL,   OPERATIVE,   AND    MECHANICAL 


JOHN  A.  WYETH,   M.  D. 


PROFESSOR  OF  SITRGERY  IN  THE  NEW  YORK   POLYCLINIC  ;    SURGEON  TO  MOUNT  SINAI  HOSPITAL  ; 

CONSULTING  SURGEON  TO   ST.   ELIZABETH'S   HOSPITAL  ;    SEEMBER  OF  THE  NEW  YORK  PATHOLOGICAL  SOCIETT  ; 

OF  THE   NEW  YORK   SURGICAL  SOCIETY  ;    OF  THE   ACADEMY  OF  MEDICINE  ; 

OP  THE  NEW  YORK   STATE   ilEDICAL  ASSOCIATION  ;    OF  THE  NEW  YORK  COUNTY  MEDICAL  SOCIETY  ; 

HONORARY    MEMBER   OF   THE   TEX!4,S    STATE   MEDICAL   ASSOCIATION  ; 

OF  THE    COLLEGE    OF   PHYSICIANS   AND    SURGEONS    OF  LITTLE   ROCK,    ARKANSAS  ; 

AUTHOR   OF  AN    ESSAY  ON    THE    SURGICAL   ANATOMY  OF  THE    TIBIO-TARSAL   REGION, 

■mTH    SPECIAL    REFERENCE   TO   AMPUTATIONS   AT   THIS   JOINT, 

AWARDED   THE  JAMES    R.    WOOD   ANNUAL  PRIZE   OF   THE   BELLEVUE   ALUMNI  ASSOCIATION,    1876  ; 

AN  ESSAY   ON   THE    SURGICAL   ANATOMY   AND   HISTORY   OF   THE   CAROTID   ARTERIES, 

AWARDED   THE   FIRST   PRIZE   OF  THE  AMERICAN    MEDICAL  ASSOCIATION,    1878  : 

AN  ESSAY  ON  THE  SURGICAL  ANATOMY  AND  HISTORY  OF   THE  INNOMINATE  AND  SUBCLAVIAN   ARTERIES, 

AWARDED  THE  SECOND  PRIZE  OF  THE  AMERICAN   MEDICAL  ASSOCIATION,   1878,   ETC. 


SECOND  EDITION 
REVISED  AND  ENLARGED 


NEW    YOKK 

D.  APPLETOisr  a:n^d  company 

1890 


■5>-"-J'/'" 


Copyright,  1887,  1890, 
By  D.  APPLETON  AND  COMPANY. 


TO     THE     MEMORY     OF     MY     FEIEND, 

J.    MARIOX    SmS,   M.D., 

WHOSE   BRILLIANT   ACHIEVKMENTS   CARRIED 

THE   FAME   OP   AMERICAN   SURGERY 

THROUGHOUT    THE    CIVILIZED    WORLD, 

THIS    BOOK    IS    AFFECTIONATELY    DEDICATED 

BY     THE     AUTHOR. 


PEEFAOE    TO   THE    SECOND   EDITION. 


In  revising  this  work  scarcely  a  chapter  remains  untouched. 
While  some  are  not  materially  altered,  others  are  practically  re- 
written. In  the  chapter  on  Inflammation  is  embodied  the  latest 
accepted  ideas  of  surgical  septicaemia.  The  article  on  the  Eye  is 
new,  and,  in  addition  to  the  surgery  of  this  organ,  includes  the 
study  of  Eefraction,  and  the  application  of  glasses  in  correcting  errors 
in  the  visual  apparatus.  The  most  recent  and  approved  methods  of 
dealing  with  lesions  of  the  abdominal  viscera — viz.,  intestinal  anasto- 
mosis, exsection  of  a  portion  of  the  alimentary  canal,  procedures  for 
the  radical  cure  of  hernise,  cholecystotomy,  etc. — have  been  added 
to  the  text.  A  new  chapter  on  the  Surgery  of  the  Grenito-Urinary 
Organs  of  Females  is  inserted.  Supra-j^ubic  cystotomy  for  stone  or 
tumor  of  the  bladder  is  given  a  prominence  not  hitherto  accorded 
so  valuable  a  procedure ;  and  scarcely  less  useful  are  the  plastic 
operations  for  the  cure  of  urinary  fistulee.  In  the  department  of 
Diseases  of  the  Rectum  and  Anus  the  latest  methods  of  surgical 
interference  are  considered. 

The  author  acknowledges  gratefully  the  assistance  received  from 
his  friends.  Prof.  David  Webster,  in  the  article  on  Refraction,  and 
Dr.  W.  W.  Van  Arsdale,  who  is  wholly  responsible  for  the  greatly 
improved  index. 

The  drawings  for  many  of  the  new  cuts  were  done  by  Dr.  Henry 
Macdonald,  of  New  York  city,  whose  thorough  work  is  well  attested. 

The  Author. 


PREFACE    TO   THE   FIRST   EDITION". 


The  author  has  endeavored  to  give  in  the  following  pages  the 
accepted  facts  in  surgical  pathology  and  diagnosis,  together  with  the 
methods  of  treatment  which  modern  surgery  has  introduced,  or  has 
elected  as  worthy  of  continued  application  from  the  practice  and 
teaching  of  the  past.  In  the  effort  to  condense  into  a  single  vohime, 
of  about  eight  hundred  pages,  the  essentials  of  the  science  and  art  of 
surgery,  not  only  is  a  discussion  of  theories  out  of  the  question,  but 
many  measures  of  treatment — the  comparative  usefulness  of  which  has 
been  demonstrated — must  of  necessity  be  omitted. 

In  an  age  when  books  upon  this  subject  are  plentiful,  this  work 
was  undertaken  not  without  misgi^'ings,  yet  with  a  determination  to 
leave  nothing  undone  which  would  add  to  its  usefulness  and  make  it 
an  exponent  of  modern  and  progressive  surgery.  Such  rapid  advances 
are  being  made,  that  marvelous  results  are  to-day  achieved  by  meas- 
ures unknown  to  the  profession  but  a  few  months  earlier.  The  intro- 
duction of  cocaine  JiydrocJilorate  as  a  local  ansesthetic  marks  an  epoch 
in  surgical  practice ;  and  yet  this  wonderfiil  agent  has  scarcely  been 
mentioned  in  works  on  surgery.  Again,  the  antiseptic  metJiod  of 
treating  wounds,  originated  within  the  last  few  years,  has  brought 
with  it  such  protection  to  life  and  usefulness,  that  it  deserves  a  more 
thorough  consideration  than  is  often  allotted  it  by  surgical  writers, 
and  should  be  universally  accepted  and  practiced. 

The  author  believed  that  the  general  profession  was  not  sufficiently 
impressed  with  the  dangers  in  delaying  surgical  interference  in  lesions 
of  the  cavities  and  their  viscera,  notably  the  cranium,  abdomen,  and 
pelvis.  These,  and  other  considerations  which  will  be  found  in  the 
text,  were  among  the  reasons  which  led  him  to  hope  that  this  book 


viii  PREFACE  TO   THE   FIRST  EDITION. 

would  prove  acceptable  to  his  fellow-workers,  and  especially  to  that 
numerous  class  of  physicians  who  are  compelled  to  do  a  general  prac- 
tice, and  who  can  find  neither  time  nor  opportunity  to  select  from 
the  vast  quantity  of  surgical  literature  the  facts  essential  to  the 
prompt  and  successful  management  of  their  cases.  That  this  hope 
was  not  without  foundation  is  attested  by  the  reception  accorded  to 
the  work  by  the  medical  press,  and  by  the  necessity  of  a  second  issue 
within  three  months  after  its  publication. 

To  the  many  sources  from  which  much  needed  help  in  its  com- 
pilation and  illustration  was  obtained — however  accredited  in  the  text 
— the  aiithor  desires  to  acknowledge  an  especial  indebtedness,  and  to 
the  engravers,  Messrs.  H.  Senior  and  Company,  for  the  general  excel- 
lence and  prompt  execution  of  their  work.  An  examination  of  the 
volume  will  attest  the  liberality  of  the  publishers,  who  have  contrib- 
uted greatly  to  its  success. 

The  Authoe. 

April  20,  1887. 


COi^TES'TS. 


CHAPTER  L 

PAGE 

Surgical  dressings — Ligatures  and  sutures — Preparation  of  material — Catgut,  silk,  sUk-worm 
gut,  silver  wire — Antiseptic  solutions — Corrosive  sublimate,  creoline,  carbolic  acid,  iodo- 
form, alcohol,  ohiloride-of-zinc — Irrigators,  sponges — Drains:  rubber,  bone,  catgut,  and 
horse-hair — Protective — Carbolized,  subUmated,  and  iodoformized  gauze — Berated  and 
absorbent  cotton — Peat — Sawdust — Jute — Wood-wool 1 

CHAPTER  II. 

Bandaging — Materials  and  methods  of  preparing — Application  of  the  various  methods — Simple 
spiral,  reverse  spiral,  figure-of-8  turn,  figure-of-8  reverse — ^Special  bandages — Hand  and 
fingers — Fore-arm,  arm,  and  shoulder — Toes,  foot,  leg,  and  thigh — Spica — Abdomen  and 
thorax — Head  and  face — Knotted  bandage — Handkerchief  bandages 10 

CHAPTER  III. 

Anesthesia — Local  anesthesia — Cocaine — Ether-spray — General  anaesthesia — Administration 
of  ether  by  inhalation — By  the  rectum — Chloroform  and  chloroform  narcosis     .        .        .22 

CHAPTER   IV. 

Surgical  operations — Instruments — Operating  -  table — Furniture — Operating-gown — How  to 
hold  the  scalpel — Haemostasis — Tying  the  Ligature — After-treatment  of  the  case        .        .    35 

CHAPTER  V. 

Inflammation — Venesection  and  blood-letting — Compression — Application  of  cold — Internal 
medication — Suppuration — Pus — Micrococci — Bacteria — Abscess — Treatment    .        .        .54 

CHAPTER  VI. 

Wounds — Process  of  repair — Cicatrization — The  tourniquet — Closing  wounds — The  inter- 
rupted, continuous,  mattress,  quiU,  wire,  and  pin  sutures — Transfusion — Intra-venous 
injection  of  a  saline  solution — Poisoned  wounds — Snake-bites — Tarantula-poison — Wounds 
by  bees,  wasps,  hornets,  and  centipedes — Hydrophobia — Glanders — Malignant  pustule — 
Dissection  woimds  —  Erysipelas — Dermatitis  —  Erythema  —  Cellulitis  —  Tetanus — Shot- 
wounds     68 

CHAPTER  Yll. 

Bums  and  scalds — Skin-grafting — Frost-bite — Furuncle — Carbuncle — Ulcers— Gangrene — Dry 
or  senile  gangrene — Hospital  gangrene 93 


X  COISTTENTS. 

CHAPTER  VIII. 

PAGE 

Amputations— Method  of  operating— Circular  solid  flap,  witli  perpendicular  slit— Oblique  solid 
flaps  by  transfixion — The  same  by  cutting  from  the  surface  inward — Skin-flaps,  circular 
method — Modified  circular — Oval — Double  crescentio — Double  rectangular — Mixed  flaps- 
Open  method — Special  amputations  —  Fingers — Hand — Fore-arm — Elbow-joint — Arm — 
Shoulder— Toes— Through  the  metatarsus— Through  the  tarsus— Methods  of  Pirogoff, 
Chopart,  Hey,  Lisf ranc,  Le  Fort,  LigneroUes,  and  Hancock — Tibio-tarsal  disarticulation — 
Method  of  Syme  —  Leg— Method  of  Stephen  Smith— Knee-joint— Thigh — Hip-joint — 
Method  of  Erskine  Mason,  etc.        . 107 

CHAPTER  IX. 

Surgical  diseases  and  surgery  of  the  lymphatic  vessels,  veins,  and  arteries— Lymphangitis — 
Adenitis — Phlebitis — Arteritis — Arterial  thrombosis  and  embolism — Vascular  tumors — 
Arterial  varix — Cirsoid  arterial  tumor — Angiomata — Venous  varix  or  varicose  veins — 
Moles — Port-wine  mark 162 

CHAPTER  X. 

Aneurism — Varicose  aneurism — Aneurismal  varix — Method  of  Tufnell  and  Valsalva — Ligature 
by  the  methods  of  Antyllus,  Wardrop,  Anel,  Hunter,  and  Brasdor — Digital  and  me- 
chanical pressure — Galvano-puneture,  massage,  flexion,  introduction  of  wire,  horse-hair, 
catgut,  etc. — Special  aneurisms — Aneurism  of  the  thoracic  aorta — Innominate — Common, 
external,  and  internal  carotid  arteries — Subclavian — Abdominal  aorta — Iliac  arteries — 
Femoral — Popliteal — Arterio- venous  aneurism — Simultaneous  deligation  of  left  subclavian 
and  left  common  carotid  arteries  for  aneurism  of  the  transverse  arch  of  aorta    .        .        .  202 

CHAPTER  XI. 

Ligation  of  arteries^Innominate — Common,  external,  and  internal  carotid  and  internal  jugu- 
lar vein — Superior  thyroid,  lingual,  facial,  ascending  pharyngeal,  occipital,  posterior  au- 
ricular, temporal,  and  internal  maxillary — Subclavian — Vertebral  and  internal  mammary- 
Axillary — Brachial — Radial — Ulnar — Intercostal — Abdominal  aorta — Iliac  arteries— Glu- 
teal, internal  pudic,  and  sciatic — Femoral — Profunda  femoris — Popliteal— Posterior  tibial 
— Anterior  tibial — Dorsalis  pedis 234 

CHAPTER  XII. 

Surgical  diseases  and  surgery  of  the  bones — Ostitis — Osteo-periostitis — Osteomalacia^Rachitis 
— Fractures — Of  the  skull — Trephining — Nasal  bones — Malar — Superior  maxilla — Inferior 
maxilla — Clavicle — Acromion  and  coracoid  process — Glenoid  process — Spine  of  the  scapula 
— Humerus — Condyles — Olecranon  process  — LTlna — Radius — Colles's  fracture — Carpus — 
Metacarpus — Phalanges — Sternum — Ribs — Vertebrfe  —  Sacrum  —  Coccyx — Os  innomina- 
tum — Femur — Patella — Leg — Pott's  fracture — Tarsus  and  metatarsus— Ununited  fract- 
ures . 275 

CHAPTER  XIIL 

Surgery  of  the  articulations — Dislocations — Lower  jaw — Clavicle — Shoulder-joint — Elbow-joint 
— Wrist-joint — Carpo-metacarp.al  joints  —  Phalanges  —  Hip-joint — Knee-joint — Patella — 
Tarsus — Vertebrte — Ribs — Diseases  of  the  joints  in  general — Synovitis — Arthritis — Dis- 
eases of  special  joints — Hip-joint — Morbus  coxm — Knee-joint — Ankle-joint — Shoulder-joint 
— Elbow-joint — Wrist-joint — Exsections  of  the  joints 325 

CHAPTER  XIV. 

Regional  surgery — The  head — Tumors  of  the  scalp— Abscess — Pneumatocele— Encephalocele— 
Meningocele — Neoplasms  of  the  meninges — Hydrocephalus — Wounds  of  the  scalp — Of  the 


CONTENTS.  xi 

PAGE 

brain — Cerebral  localization — Surgery  of  the  face — The  eye — The  eyelids — Lachrymal 
glands  and  ducts — The  conjunctiva  and  cornea — Sclerotic — Iris — Choroid  and  ciliary 
body — Crystalline  lens — The  vitreous — The  retina — Strabismus — Refraction — The  oph- 
thalmoscope— Testing  for  glasses — Ophthalmoscopy — Surgery  of  the  ear — The  nose — 
Plastic  surgery  of  the  nose — The  lips  and  cheeks — Parotid  gland  and  duct — Parotitis — 
Submaxillary  gland — The  jaws — Operation  for  removal  of  the  upper  jaw — The  lower  jaw 
— The  teeth — The  palate — The  tongue  and  buccal  cavity — TonsOs 383 


CHAPTER  XV. 

The  neck — Wounds — Abscess — Tumors — Thyroid  body — The  larynx  and  trachea — Thyrotomy 
— Laryngotomy — Tracheotomy — Intubation  of  the  larynx — Foreign  bodies  in  the  air- 
passages — Laryngectomy — Neoplasms  of  the  larynx  and  treachea — Pharynx — Oesophagus 
— Foreign  bodies — ffisophagotomy  for  stricture — New  formations — Qisophagectomy .        .  491 


CHAPTER  XVI. 

Thorax — Mammary  gland — Mastitis — Abscess — Hypertrophy — Tumors — Exsection  of  the  clav- 
icle— Bmpysema — Wounds  of  the  chest 513 


CHAPTER  XVH. 

Abdomen  —  Stomach  —  Gastrostomy  — Pylorectomy  —  Gastrectomy  —  Gastro-pylorectomy — 
Gastro-enterostomy — Duodenum — Obstruction  of  the  alimentary  canal — Impaction  of 
fecal  matter — Foreign  bodies — Intussusception — Volvulus — Constriction  by  bands — Ad- 
hesions— Omental  and  mesenteric  slits — Diverticula — Neoplasms — Stricture — True  hernia 
— Abdominal  section  for  intestinal  occlusion — Exsection  of  the  intestine — Intestinal  anas- 
tomosis— Hernia — Special  forms  of  hernia — Inguinal,  congenital,  infantile,  femoral,  um- 
bilical, ventral,  diaphragmatic,  gluteal,  obturator,  lumbar,  and  vaginal  hernia — Radical 
cure  of  hernia — Stangulated  hernia — Fecal  fistula — Imperforate  anus — Colostomy — Peri- 
tonitis— Abdominal  abscess — Perityphlitis — The  liver — The  gall-bladder — The  spleen — 
Wounds  of  the  abdomen 526 


CHAPTER  XVIII. 

Rectum  and  anus — Atresia  ani  et  recti — Pruritus  ani — Foreign  bodies — Fistula  in  ano  et  recto 
— Fissure — Ulcers — Stricture — Neoplasms  of  the  rectum  and  anus — Neuralgia — Prolap- 
sus— Hiemorrhoids 591 


CHAPTER  XIX. 

Genito-urinary  organs — Kidneys — Suppression  of  urine — Nephrotomy  and  nephrectomy — Ure- 
ters— Bladder — Wounds — Infiltration  of  urine — Cystitis— Paralysis — Incontinence — Neo- 
plasms— The  urine — Stone — Lithotrity — Lithotomy — Prostate  body— Spermatorrhoea — 
Asperraatism — Urethra  —  Gonorrhcea — Balanitis — Posthitis — Gonorrhoeal  rheumatism — 
Gleet — Stricture — Meatomy — Internal  urethrotomy — Dilatation — Modified  internal  ure- 
throtomy— External  urethrotomy  or  perineal  section — Sounds — Foreign  bodies  in  the 
urethra — Congenital  and  acquired  malformations — Neoplasms — Cancer  of  the  penis — Am- 
putation— Humphrey's  operation — Phimosis — Circumcision — Dilatation  of  the  prepuce — 
Ulcers  of  the  penis — Syphilis — Scrotum — Hydrocele — Varicocele — Epididymis — Testicle  .  619 

CHAPTER  XX. 

The  genito-urinary  organs  in  females — Lesions  of  the  vulva  and  perinseum — Operations  for 
lacerations  of  the  perinaeum — Diseases  of  the  vulva — The  vagina — Vaginitis — Vaginismus — 
Stricture — Narrowing  the  vagina — Vesico-vaginal  fistula — Cervix  uteri — Excision  and  am- 


CONTENTS. 


putation  of  the  cervix — Vaginal  hysterectomy — Hysterotomy — Hysterectomy  during  preg- 
nancy— Abdominal  hysterectomy — The  Fallopian  tubes — The  ovaries — Laparotomy  for 
the  removal  of  tumors  of  the  ovary  and  Fallopian  tubes 751 


CHAPTER  XXI. 

Deformities  of  the  spine — Torticollis — Lateral  and  rotary-lateral  curvature — Scoliosis — Cypho- 
sis — Spondylitis — Spina  bifida — Deformities  of  the  lower  extremity — Preternatural  mo- 
bility of  the  hip — Sub-trochanteric  osteotomy — Genu  valgum — Genu  varum — Talipes — 
Polydactylus — Syndactylus— Hallux  valgus — Hammer-toes — In-growing  nail — Deformi- 
ties of  the  upper  extremity— Club-hand — Web-flnger — Snap-finger — Phlegmon  of  the 
hand  and  fingers — Ganglion 779 

CHAPTER  XXII. 

Tumors — Carcinoma — Epithelioma  —  Lymphadenoma  —  Sarcoma  —  Papilloma  —  Adenoma  — 
Cysts — Lipoma — Fibroma — Myxoma — Myoma — Neuroma — Angioma — Lymphangioma  — 
Chondroma — Osteoma 837 


TEXT-BOOK    O^    SURGERY. 


CHAPTER  I. 

STJEGICAL  DKESSIIfGS. 


The  materials  used  in  the  performance  of  a  surgical  operation,  and  in 
its  after-treatment,  form  such  an  important  part  of  the  surgeon's  outfit 
that  I  have  determined  to  devote  the  initial  chapter  of  this  book  to  a 
description  of  the  methods  of  preparing  and  preserving  the  apparatus 
needed  for  dressing  wounds  in  the  antiseptic  practice  of  to-day. 

This  practice,  which  embodies  the  great  principles  of  cleanliness  and 
carefulness  in  surgery,  is  now  so  well  established  among  the  best  sur- 
geons in  America  and  Europe  that  any  argument  in  its  favor,  as  compared 
with  the  methods  of  one  or  two  decades  ago,  I  consider  to  be  wholly 
unnecessary. 

Ligatures  and  Sutures. — Catgut,  silk,  sUk-worm  gut,  and  silver  wire 
will  meet  every  requirement  in  tying  vessels  and  closing  wounds.  Catgut 
has  practically  superseded  all  other  substances  as  a  Kgature.  The  con- 
ditions which  would  justify  the  application  of  a  silk,  metal,  or  any  non- 
absorbable ligature  to  an  artery  are  rarely  present.  Strings  or  cords 
made  fi'om  animal  tissues,  as  buckskin,  ox-aorta,  nei've,  tendon,  and 
whalebone,  known  under  the  general  name  of  "  broad  ligatures, ''  have 
been  successfully  employed  in  the  occlusion  of  the  larger  vessels,  but 
their  use  is  limited  in  comparison  with  that  of  the  violin-strings,  which 
are  easily  obtained,  prepared  and  preserved,  and  are,  moreover,  cheap. 

In  the  preparation  of  catgut  select  four  sizes  of  the  best  quality  of 
violin-strings  in  about  this  proportion :  one  dozen  each  of  the  E  and  A 
strings,  six  D  strings,  and  two  or  three  harp-strings  about  twice  as  large 
as  that  of  D,  violin.  The  smaller  sizes  are  most  generally  needed  for  the 
smaller  vessels  and  bleeding  points,  the  D  string  is  best  adapted  to  ves- 
sels as  large  as  the  radials,  ulnars,  or  tibials,  while  the  larger  strings 
should  be  used  upon  the  iliacs,  subclavians,  common  carotids,  and 
femorals. 

Preparation. — Cut  and  remove  the  small  red  threads  which  are  tied 
around  each  bunch,  and  place  the  catgut  in  a  glass  bottle  or  jar  which 
1 


2 


A  TEXT-BOOK  ON  SURGERY. 


contains  enough  pure  oil  of  juni-per -berries  to  completely  cover  them. 
The  vessel  should  be  tightly  corked  to  prevent  evaporation.  Within 
a  few  days  the  material  is  safely  aseptic,  and  will  remain  so  indefinitely 
if  kept  immersed  in  the  fluid.  It  is  advisable,  how- 
ever, to  transfer  the  gut  to  pure  alcohol  after  a  week's 
immersion  in  the  juniper  oil  and  preserve  it  indefi- 
nitely in  this  liquid.  Alcohol  keeps  this  material  clean 
and  does  not  materially  interfere  with  its  strength. 

If  oil  of  juniper  can  not  be  obtained,  the  alcohol 
may  alone  be  used.  Fig.  1  repi'esents  a  convenient 
apparatus  for  holding  these  ligatures.  It  consists  of  a 
glass  jar  or  bottle,  with  a  wide  mouth,  in  which  a  per- 
forated cork  is  fitted.  Within  the  bottle  are  several 
glass  spools  upon  which  the  ligatures 
have  been  wound.  The  ends  project 
through  the  perforation  in  the  cork,  and 
are  held  here  by  a  smaller  cork  fitted 
^10-  1-  into   the    perforation.      Upon  removing 

the  smaller  plug,  the  threads  may  be 
drawn  out  and  cut  off  as  required.  Another  vessel  is 
pictured  in  Fig.  2.-  In  this  the  ligatures  are  wound 
around  a  central  shaft,  which  is  pulled  completely  out 
of  the  bottle  when  the  threads  are  needed. 

Cliromic-acid  Gatgut. — When  an  animal  ligature  or 
suture  which  will  resist  absorption   and  hold  its  grasp  fie.  2. 

upon  the  tissues  longer  than  ordinary  juniper  or  alcohol 
catgiit  is  desired,  this  material  should  be  submitted  to  the  tanning 
action  of  chromic  acid.     The  formula  of  Dr.  F.  L.  Burt  yields  the  best 
suture  of  this  kind. 

Take  a  1  to  20  solution  of  carbolic  acid  in  water  (gr.  xx  of  water  by 
weight  to  gr.  j  of  carbolic  acid),  and  in  this  dissolve  chromic  acid  in  the 
proportion  of  gr.  j  of  the  crystals  to  gr.  5,000  by  weight  of  the  carbolic 
solution. 

When  this  solution  is  ready,  drop  the  violin  strings  in  it  and  allow 
them  to  remain  immersed  until  when  lifted  out  the  gut  retains  the 
same  amber  stain  or  color  of  the  liquid.  From  four  to  six  hours  will 
usually  suffice,  but  the  test  should  be  the  color  of  the  catgut.  It 
should  then  be  thoroughly  dried  and  placed  in  clean,  tight  bottles. 
When  about  to  be  used  it  should  be  softened  for  about  one  half-hour 
in  a  1  to  1,000  solution  of  sublimate  or  a  1  to  20  carbolic-acid  solu- 
tion. For  such  sutures  the  smaller  strings  are  preferable.  E  violin  is 
about  the  proper  size.  Thus  prepared,  catgut  will  resist  absorption  from 
one  to  three  weeks. 

SWi  is  invahiable  for  sutures.  It  is  not  to  be  used  for  ligatures,  ex- 
cept in  certain  operations  vdthin  the  abdominal  cavity,  or  in  wounds 
which  are  to  be  treated  by  the  open  method.  This  material  should  be 
selected  of  all  sizes.  I  prefer  the  twisted  to  the  braided  threads,  although 
the  latter  is  less  likely  to  become  tangled.     The  very  finest  hlack  iron- 


SURGICAL  DRESSINGS. 


dyed  silk  is  needed  in  the  plastic  surgery  of  the  neck  and  face,  in  the 
white  individual.  "White  sutures  often  become  so  discolored  that  they 
are  with  difficulty  found  when  the  time  for  their  removal  arrives.  The 
larger  silk  sutures,  such  as  those  employed  in  tying  hfemorrhoidal 
masses,  should  be  so  strong  that  any  ordinary  force  can  not  break  them. 
Silk  is  rendered  aseptic  by  boiling  and  then  preserving  in  1  to  20  carbolic- 
acid  or  1  to  3,000  sublimate  solution. 

Silk-ioorm  gut  comes  in  bristles,  or  stiff  threads,  about  ten  inches  in 
length.     It  serves  as  an  excellent  suture  in  any  part  of  the  economy,  and 
is  invaluable  in  the  operation  for  cleft  palate.     It  is  not  ab- 
sorbable,  is  very  strong,  ties  easily,   and  does  not  slip.     It 
should  be  kept  in  an  ordinary  dry  box,   and  need  not  be 
rendered  aseptic  for  operations  on  the  palate. 

Silver  wire  is  essential  as  a  suture-material.  Beyond  the 
operations  upon  the  genito-urinary  organs  of  the  female, 
where  it  is  indispensable,  it  is  preferable  to  silk  in  many 
wounds  of  other  portions  of  the  body.  The  sizes  most  re- 
qiiired  range  from  Nos.  24  to  31,  inclusive.  A  most  con- 
venient way  of  carrying  silver  for  immediate  use  is  to  cut  it 
in  pieces  about  ten  inches  in  length,  and  place  it  in  a  metal 
cylinder  (Fig.  3),  which  is  divided  into  three  or  four  compart- 
ments, and  closed  by  a  screw-top.  Or  the  -wire  Ioo^ds  may  be 
wrapi^ed  in  protective  or  blotting-paper,  and  thus  kept  free 
from  moisture  in  order  to  prevent  rust.  They  are  rendered 
aseptic  by  immersion  in  1  to  20  carbolic  acid  one  half-hour 
before  using  them. 

Solutions. — For  irrigating  wounds,  submerging  instru- 
ments, and  disinfecting  in  general,  solutions  of  corrosive  sub- 
limate, creoline,  carbolic  acid,  boric  and  salicylic  acid,  are 
necessary,  and  pure  alcohol,  iodofoiTu,  and  chloride -of -zinc 
solutions  may  at  times  be  used. 

Koch  has  demonstrated  that,  as  a  germ-killer,  corrosive 
sublimate  excels  all  known  agents.  Tlxe  sublimate  solutions 
vary  in  the  proportion  of  one  part  of  the  bichloride  to  five 
hundred  parts  of  distilled  water  by  weight,  or  1  to  500,  1  to 
1,000,  1  to  2,000,  and  1  to  3,000  for  use  outside  of  the  gTeat 
cavities,  and  1  to  8,000,  1  to  15,000,  and  1  to  20,000  within 
the  cavities. 

The  sublimate  solutions  are  only  used  for  ii-rigation  and 
for  disinfecting  the  hands,  sponges,  and  gauze.  AU  instru- 
ments are  submerged  in  carbolic-acid  solutions  or  in  alcohol. 

The  stronger  solutions,  1  to  500  and  1  to  1,000,  are  rarely 
employed  in  irrigation,  and  then  only  when  the  part  exposed 
has  been  made  bloodless  by  the  Esmarch  bandage.  Even 
when  thus  employed  for  the  disinfection  of  an  abscess  cav- 
ity, infected  wound,  ulcer,  or  sinus,  the  excess  of  sublimate  should  be 
immediately  washed  away  by  flooding  the  part  with  the  1  to  3,000 
solution,      in  any  ordinary  operation  no  stronger  sublimate  than  1  to 


4,  A  TEXT-BOOK   ON  SURGERY. 

3,000  will  be  required ;  a  1  to  18,000  solution  may  be  iised  in  the  peri- 
toneal cavity  where  the  conditions  are  such  that  the  fluid  may  run  out 
or  be  removed  at  once  by  sponges.  I  have  tilled  the  entire  abdominal 
cavity  with  warm  sublimate,  1  to  18,000,  mopping  it  out  with  sponges, 
and  repeating  this  procedure  three  times  without  any  bad  symptom 
resulting.  In  the  laleural  cavity  (emj)yema)  much  stronger  solutions 
may  be  employed. 

For  convenience,  any  required  solution  may  be  made  from  the 
following :  Corrosive  sublimate,  gr.  xxx ;  water  §  j.  Some  add  to 
this  about  gr.  x  of  table-salt.  One  teaspoonful  of  this  solution  add- 
ed to  a  pint  of  water  approximates  1  to  2,000.  Water  containing 
lime  should  not  be  used.  Tablets  of  corrosive  sublimate  are  now 
manufactured,  and  are  very  convenient  for  transportation.  Each  tab- 
let contains  enough  sublimate  to  make,  when  dissolved  in  a  pint  of 
water,  a  1  to  1,000  solution.  It  is  best  to  make  fresh  solutions  when 
needed,  for,  unless  kept  tightly  corked  and  away  from  light,  they  de- 
teriorate in  value. 

CreoUne,  a  product  of  coal-tar,  has  been  accepted  as  a  valuable 
antiseptic  agent.  It  is  a  dark-brown  colored  liquid,  not  soluble  in 
but  forming  with  water  a  milky-looking  mixture.  It  is  especially  rec- 
ommended for  the  "iiTigation  of  wounds  needing  stimulation  and  in 
those  exceptional  cases  where  the  sublimate  solutions  produce  a  trou- 
blesome dermatitis.  The  ordinary  strength  is  1  part  of  creoline  to  200 
parts  of  water. 

Carbolic  acid  (1  to  20,  or  a  5-per-cent  solution)  is  employed  for  the 
cleansing  and  submersion  of  all  instruments  used  in  a  surgical  operation. 
It  is  not  used  in  irrigation  on  account  of  its  irritating  properties.  The 
steam  and  carbolic  spray  so  much  in  vogue  a  few  years  since  is  now  only 


Fig.  4. — Weir's  antiseptic  spray-maehine. 


used  to  lay  the  dust,  or  as  an  aid  toward  the  more  thorough  cleansing  of 
operating-rooms  and  wards  which  are  especially  exposed  to  infection. 
The  spray-machine  (Fig.  4)  is  started  one  half-hour  before  the  operation 
is  to  commence,  and  is  allowed  to  run  until  that  time.  The  strength  of 
the  solution  in  the  bottle  is  1  to  20. 


SURGICAL   DRESSINGS.  5 

As  ordinarily  sold,  carbolic  acid  is  dissolved  in  alcohol,  and  is  about 
95  per  cent  strong.  In  this  condition  an  ounce  by  measurement  is  ap- 
proximately an  ounce  by  weight.  To  this  quantity  add  water  §xx, 
which  will  make  a  1  to  20,  or  5-per-cent  solution.  All  instruments  are 
immersed  in  this  solution  a  half-hour  before  the  operation,  except  the 
blades  of  the  knives,  which  should  be  dipped  in  only  a  minute  or  two 
before  being  used. 

An  exceedingly  useful  solution  for  irrigation  about  the  eye,  ear,  in 
the  pleural  cavity,  but  especially  applicable  to  the  peritoneal  cavity,  is 
composed  of  acid  salicylic,  3  j  ;  acid  boric,  3  vj  ;  hot  distilled  water,  §  xl 
— about  two  pints  and  a  half  (Thiersch's  solution).  If  made  with  cold 
water,  there  will  be  a  precipitate. 

Pure  alcoJiol  may  also  be  used  for  this  purpose  by  operators  who  dis- 
like the  benumbing  effects  or  disagreeable  odor  of  the  acid. 

Iodoform,  one  part  dissolved  in  seven  parts  of  ether,  is  used  at  times 
to  wash  the  parts  where  an  operative  wound  is  to  be  made.  It  is  not  an 
uncommon  practice  with  some  of  the  German  surgeons  to  immerse  all  the 
ligatures  and  suture- material  in  this  solution  for  about  twenty  minutes 
before  the  operation  is  begun. 

Of  the  value  of  this  agent  in  its  dry  and  pulverized  form  in  dressing 
wounds  there  is  still  considerable  diversity  of  opinion.  That  its  anti- 
septic qualities  have  been  greatly  overrated  there  is  no  doubt.  It  does 
not  prevent  infection  by  the  germs  of  erysipelas  or  those  of  anthrax. 
It  seems  to  be  proved  at  this  date  that  it  does  not  destroy  or  neutralize 
any  of  the  septic  germs ;  in  fact,  unless  sterilized — which  may  be  done 
by  washing  it  in  1  to  3,000  sublimate  solution — it  may  convey  septic 
products  to  wounds.  Moreover,  it  is  absorbable,  and  at  times  a  violent 
and  fatal  poison.  With  these  facts  in  view,  its  use  should  be  guarded 
and  limited.  It  should  not,  however,  be  totally  discarded,  for,  accord- 
ing to  Dr.  W".  W.  Yan  Arsdale  *  and  others,  its  property  of  destroying 
the  ptomaines  renders  it  useful  as  a  deodorizer,  especially  on  putrid  and 
infected  surfaces  and  on  the  mucous  surfaces,  or  in  wounds  communi- 
cating with  these  cavities. 

Cliloride-of-zino  solution  in  water  (1  to  12,  about  8  per  cent)  may 
be  used  to  wash  out  ulcers  or  old  sinuses  which  are  in  the  neighbor- 
hood of,  or  communicate  with,  the  wound  of  operation.  This  and 
the  iodoform  solution  are  not,  however,  essential,  and  are  now  rarely 
employed. 

Irrigators. — A  rubber  bag,  capable  of  holding  two  quarts  of  solution, 
with  extra  long  tubing  attached,  makes  a  convenient  irrigator  for  use  and 
transportation.  The  ordinary  fountain-syringe,  represented  in  Fig.  5,  is 
commonly  used.  The  nozzles  should  be  of  smooth  glass,  sufficiently 
heavy  to  resist  breakage,  about  three  or  four  inches  in  length,  not  more 
than  a  quarter  of  an  inch  in  gross  diameter,  slightly  pointed,  and  with  a 
lumen  of  one  eighth  of  an  inch.  Sublimate  solution  should  not  be  allowed 
to  remain  in  contact  with  rubber  for  any  considerable  time  on  account  of 

*  "  Annals  of  Surgery,"  March,  1889,  p.  215. 


A  TEXT-BOOK   ON   SURGERY. 


its  corrosive  action.     When  an  operation  or  dressing  is  completed,  after 
the  sublimate  escapes,  pure  water  should  be  run  through  the  irrigator. 

A  good  emergency  irrigator  is  shown  in 
Fig.  6.  It  is  made  by  placing  a  perforated 
cork  in  an  ordinary  wine-bottle,  fitting  a  piece  l^ 

of  glass  tube,  or  cane,  or  goose-quill  into  the  | 

perforation  to  which  the  rubber  hose  is  at-  ^ 

tached.     The  bottom  of  the  bottle  is  broken 

/    I 


in,  and  a  string  netting,  thrown  around  for 
suspension,  completes  the  apparatus.  If  there 
is  no  stop-spring  to  shut  off  the  flow,  it  may 
be  readily  arrested  by  placing  the  nozzle  in 
the  upper  end  of  the  bottle.     The  assistant  fig.  e.— (Esmarch.) 

who  attends  to  the  irrigator  can  always  regu- 
late the  flow  by  slight  pressure  of  the  tul)e  between  the  thumb  and  finger, 
just  where  the  nozzle  is  attached.     Tin  or  brass  vessels  may  also  be  em- 
ployed, but  the  corrosive  action  of  the  mercury  soon  destroys  the  metal. 

When  no  irrigator  can  be  had,  the  sublimate  solution  may  be  poured 
on  from  a  pitcher  or  cup. 

For  continuous  irrigation,  as  in  an  amputation  treated  by  the  open 
method,  a  constant  dripping  may  be  secured  by  twisting  a  piece  of  muslin 
or  cotton  cloth  into  a  loose  wick-like  string,  moistening  it,  and  placing 
one  end  in  a  vessel  holding  the  solution,  wdiile  the  other  hangs  over  the 
edge  from  a  point  where  the  fluid  will  fall  on  the  wounded  surface 
(Fig.  7). 

Sponges. — In  selecting  sponges,  secure  those  of  softest  and  finest  text- 
ure, measuring,  when  dry,  from  one  to  two  and  three  inches  in  diametei% 
the  greater  number  spherical  in  shape,  with  a  half-dozen  flat  pieces  a 
half -inch  thick,  three  or  four  inches  wide,  and  from  six  to  ten  inches  long. 
When  purchased  in  the  rough  they  should  be  thoroughly  whipped 
until  all  the  sand  is  removed,  and  then  washed  in  cold  or  lukewarm 


SURGICAL   DRESSIXGS.  7 

water.     Two  methods  may  be  employed  for  bleacMng,     The  simpler  way 
is  to  soak  them  for  from  six  to  eighteen  hours  in  a  mixture  of  one  part 


of  liquor  sod?e  chlorinatse  to  five  of  water,  rinse  them  in  clear  cold  water, 
and  dry  thoroughly.  A  more  complicated  but  very  efBcacious  method  is 
the  following  :*  Place  the  sponges  in  a  solution  of  permanganate  of  po- 
tassa,  1  to  100  (about  gr.  v-  3  j  of  water),  for  one  half -hour ;  rinse  in  clear 
cold  water,  squeeze  thoroughly,  and  immerse  them  in  a  solution  of  oxalic 
acid  (1  to  50)  for  ten  minutes.  Einse  again  in  clear  water,  leave  them 
there  for  one  hour,  and  then  dry  quickly  in  a  warm  oven.  Sponges  may 
be  kept  dry  either  in  tightly  corked  glass  or  stone  jars,  or  wrapped  up  in 
protective,  and  put  away  in  a  clean  drawer.  They  may  also  be  kept 
indefinitely  in  a  1  to  20  carbolic-acid  solution,  but  should  not  be  kept  any 
length  of  time  in  sublimate  solution. f  When  a  sponge  has  been  once 
used  it  should  be  destroyed^  unless  the  circumstances  are  such  that  other 
and  fresh  pieces  can  not  be  obtained  for  a  succeeding  operation.  Even 
under  such  conditions,  if  they  have  been  brought  in  contact  with  septic 
matter,  it  should  be  imperative  to  destroy  the  sponges  and  proceed  -nith- 
out  them,  using  clean  cloths,  or  towels,  or  borated  or  absorbent  cotton  in 
their  stead. 

To  cleanse  sponges  which  have  been  used,  wash  them  thorough- 
ly in  different  changes  of  warm  water  (not  hot),  and,  when  they  no 

*  To  Mr.  Angelo,  druggist,  of  Fourth  Avetine  and  Thirty-first  Street,  Xew  York,  I  am 
indebted  for  this  formula. 

t  Mr.  Charles  G.  Am  Ende,  168  Washington  Street,  Hoboken,  New  Jersey,  prepares  sponges 
that  are  soft,  clean,  and  very  satisfactory,  as  well  as  cheap. 


A  TEXT-BOOK  ON  SURGERY. 


longer  discolor  clear  water,  immerse  tliem  in  1  to  500  sublimate  for  one 
hour. 

In  ali  operations,  sponges,  before  being  used  in  the  wound,  should  be 
dipped  in  1  to  3,000  sublimate  solution,  and  then  squeezed  as  dry  as 
possible. 

Drains. — Rubber  tubing,  Neuber's  bone  drains,  and  twists  of  catgut 
or  Jwrse-Jiair,  are  chiefly  to  be  relied  upon  in  draining  wounds.  Rubber 
is  most  generally  useful.  The  softest  tubing  should  be  selected,  of  vari- 
ous sizes,  from  that  which  has  a  lumen  of  one  half-inch  in  diameter  down 
to  one  sixteenth.  Before  it  is  inserted  it  should  be  bent  over  the  finger, 
and  with  a  pair  of  curved  scissors  clipped  full  of  holes  about  a  half -inch 
apart,  as  seen  in  Fig.  8.  Rubber  drains  should  be  kept  dry  in  clean  jars, 
from  which  they  are  taken  and  placed  in  1  to  20  carbolic  acid  solution 
when  the  operation  for  which  they  are  needed  is  begun.  When  a  wound 
is  to  be  dressed  only  once — the  "permanent  dressing" — absorbable  ani- 
mal drains  should  be  inserted.  For  this  purpose  Neuber's  bone  tubes 
(Fig.  9)  are  preferable.  They  are  made  from 
the  bones  of  young  and  healthy  animals.  The 
crude  bone  is  cut  of  proper  length  and  size, 
bored  out,  turned  on  a  lathe  round  and  smooth, 
and  perforated  laterally.  Immersion  in  33- 
per-cent  muriatic  acid  for  twelve  hours  com- 
pletely decalcifies  them,  after  which  they  are 
kept  (as  recommended  by  the  inventor)  in  1 
to  20  carbolic-acid  solution,  frequently  re- 
newed. I  prefer  to  keep  them  in  alcohol,  95 
per  cent,  or  oil  of  juniper,  which  preserves 
them  aseptic  and  hardens  them,  rendering  a 
too  rapid  absorption  less  likely.  Tlie  tubes 
are  from  three  to  five  inches  long.  There  are 
four  sizes :  the  caliber  of  No.  1  is  six,  No.  2  is 
five,  No.  3  is  four,  and  No.  4  three  millimetres 
in  diameter  (one  millimetre  is  approximately 
^  of  an  inch).  The  walls  are  from  one  to  one 
and  a  half  millimetre  in  thickness. 

These  drains  can  be  prepared  readily  from  fig.  s.       Fig.  9.    fig.  lo. 

the  bones  of  fowls  by  scraping  the  perios- 
teum off  and  the  marrow  out,  soaking  in  muriatic  acid  (33-per-cent  solu- 
tion) as  above,  and  then  in  ether  for  a  few  hours  before  transferring  them 
to  the  alcohol.*    Bone  drains  will  be  absorbed  in  from  five  to  twenty 
days,  and  are  excellent  in  permanent  dressings. 

Catgut  or  horse-Tiair  twists  or  skeins  are  at  times  employed  for  drain- 
ing small  wounds,  and  are  very  satisfactory.  The  violin-strings  are 
twisted  into  a  bunch,  as  shown  in  Fig.  10,  and  laid  in  the  wound  at  vari- 

*  If  the  bones  used  are  from  fowls  wliich  have  been  cooked,  Macewen  recommends  that 
the  hydrochloric-acid  solution  should  be  one  to  five  of  water,  and  that  the  tube,  when  in- 
serted into  the  wound,  should  be  threaded  with  horse-hair  to  prevent  collapse  from  pressure, 
and  to  facilitate  the  removal  of  clots  without  taking  out  the  tube  and  irritating  the  wound. 


SUEGICAL  DRESSINGS.  9 

ous  points,  so  as  to  project  at  the  lower  angles  or  in  such  positions  as 
will  secure  the  most  perfect  drainage.  The  hair  is  taken  from  the  mane 
or  tail,  washed  clean,  and  immersed  for  twenty-four  hours  in  oil  of 
junijjer.     It  is  twisted  in  the  same  manner  as  the  catgut. 

Protective. — Thin  rubber  tissue,  oil-silk,  or  MacMntosh  cloth,  may- 
be used  to  protect  the  part  from  atmospheric  changes,  and  to  prevent 
the  evaporation  and  volatilization  of  the  antiseptic  agents.  The  former 
is  preferable,  and  the  oil-silk  is  next  in  order.  Rubber  tissue  must  be 
kept  in  a  cool,  dry  spot,  and  should  be  di^jped  in  1  to  3,000  sublimate 
before  it  is  applied. 

G*aw2e.  ^Ordinary  cotton  muslin  of  light  texture,  commonly  known 
as  cheese-cloth,  impregnated  with  corrosive  sublimate  or  iodoform,  is 
widely  used  as  antiseptic  gauze. 

Carbolized  gauze  has  passed  out  of  use. 

To  make  sublimate  gauze  proceed  as  follows :  Cut  a  bolt  of  cheese- 
cloth into  pieces  a  yard  long,  and  place  in  boiling  water  for  eight  hours. 
Then  rinse  thoroughly  in  cold  water,  and  bleach  in  liquor  sodse  chlorinatse 
(one  part  to  five  of  water)  for  twenty-four  hours.  Rinse  again  in  clear 
water,  and  leave  the  cloth  in  a  tightly  covered  jar  or  tank  of  1  to  500 
sublimate  indefinitely.  When  the  gauze  is  about  to  be  used,  squeeze  the 
water  out  of  it  and  wet  it  in  fresh  1  to  3,000  solution,  and  again  squeeze 
it  until  it  is  only  fairly  moistened,  not  dripping,  with  the  solution.  Am 
Ende'  s  sublimate  pink  gauze  is  an  excellent  preparation.  It  is  stained 
with  eosine,  which  is  a  color-test  upon  the  purity  of  the  gauze,  for,  if  the 
mercury  is  decomposed  or  volatilized,  the  eosine  goes  with  it  and  the 
gauze  is  left  white. 

lodoformized  gauze  is  made  by  moistening  the  washed  cheese-cloth 
in  1  to  3,000  sublimate,  sprinkling  it  with  powdered  iodoform  from  a 
pepper-box,  and  then  working  the  powder  into  the  meshes  of  the  cloth 
until  it  is  a  golden-yellow  color.  It  should  be  made  fresh,  although  it 
may  be  preserved  for  one  or  two  weeks  in  tight  glass  jars,  wi-apped  in 
red  or  blue  paper  to  prevent  the  decomposition  of  light. 

Borated  absorbent  cotton  is  now  almost  indispensable  in  surgical 
practice.  It  is  used  not  only  to  protect  the  part  and  to  exercise  com- 
pression, but,  for  purposes  of  cleansing  and  dressing  wounds,  it  has  en- 
tirely superseded  sponges,  and  is  not  only  cheaper,  but  preferable  in  every 
respect.  It  is  so  difficult  to  prepare,  however,  that  the  practitioner  is 
almost  compelled  to  patronize  the  manufacturer.  When  an  emergency 
demands  it,  ordinary  ginned  cotton  of  clean  fiber  may  be  bleached  and 
softened  by  treating  it  in  the  same  way  as  given  for  the  cheese-cloth. 
It  can  be  charged  with  boracic  acid  by  immersing  it  in  a  solution  con- 
taining gr.  XV  to  1  j  of  water.  It  is  then  dried  and  wrapped  in  protect- 
ive until  needed  for  use. 

WeU-prepared  borated  cotton  is,  next  to  gauze,  the  most  suitable  ab- 
sorbent of  discharges  from  wounds.  Beyond  these  two  substances  noth- 
ing is  really  needed.  Pads  or  bags  of  peat,  sawdust,  jute,  wood-wool, 
etc.,  are  practically  useless. 


CHAPTER  II. 


BANDAGINU. 


Bandages  are  employed  in  surgical  practice  to  retain  dressings  la 
position,  to  secure  compression  and  support  to  any  portion  of  tlie  body, 
to  maintain  any  required  degree  of  immobility,  and  to  render  an  extremity 
partially  or  completely  bloodless. 

They  are  made  of  cotton  muslin  of  various  degrees  of  fineness,  crino- 
line, Avoolen  goods,  and  India  rubber.  Cotton  bandages  are  most  gener- 
ally employed,  but,  on  account  of  the  greater  elasticity  of  flannel,  these 
are  preferable  for  certain  special  dressings.  Crinoline  is  only  used  for 
plaster-of -Paris  bandages.  Martin's  rubber  bandage  and  Esmarch's  blood- 
less tourniquet  are  very  useful  in  maintaining  the  firm  compression  of  a 
part,  either  as  a  means  of  support  or  of  emptying  the  vessels. 

The  muslin  should  be  soft,  not  starched,  and  of  two  kinds — a  fairly 
heavy  quality,  and  the  light  cheese-cloth.  Both  should  be  cut  in  pieces 
from  eight  to  ten  yards  in  length.  The  former  can  be  torn ;  the  latter 
must  be  cut.  The  selvage  edge  is  removed,  and  the  cloth  divided  into 
strips  varying  in  width  from  four,  three,  two  and  a  half,  and  two  inches, 
with  some  one  inch  or  less  in  width.  For  the  chest  and  abdomen  the 
wide  bandages  are  needed,  the  two-  and  three-inch  strips  for  the  arms, 
legs,  head,  and  neck,  and  the  narrow  strips  for  the  hands  and  fingers. 
All  the  loose  ravelings  along  the  edges  should  be  pulled  off,  and  the 
bandages  made  into  compact,  smooth  rollers. 

Bandages  may  be  rolled  by  hand,  yet  it  is  a  tedious  and  tiresome 
business,  and  an  utter  waste  of  time,  when  the  work  can  be  better  and 
more  rapidly  done  by  machinery. 
In  Fig.  11  is  pictured  a  bandage- 
roller,  simple  in  construction  and 
cheap.  It  should  be  fastened  to 
the  edge  of  a  solid  table  by  screws 
or  movable  clamps.  The  end  of  the 
strip  to  be  wound  is  passed  in  and 
out  over  the  four  bars  at  the  base 
and  apex  of  the  machine,  and  then 
around  the  shaft,  so  that  one  edge 

of  the  bandage  touches  the  end  of  the  uj^right.  As  the  crank  is  turned, 
the  strip  is  held  tightly,  and,  as  it  runs  over  the  rods,  wrinkling  or  fold- 
ing is  prevented.     A  home-made  apparatus  may  be  constructed  as  fol- 


BANDAGING. 


11 


lows  :  Take  a  cigar-box,  remove  tlie  top  and  one  end,  bore  a  liole  in  each 
side-piece  near  the  open  end,  and  through  these  pass  a  piece  of  telegraph- 
wire  bent  in  the  shape  of  a  windlass  and  crank.  Wires  may  be  run 
through  at  other  points  to  serve  the  same  purpose  as  the  four  rods  in 
the  other  machine. 

In  making  plaster-of-Paris  bandages,  these  same  machines  may  be  em- 
ployed, but  the  crinoline  must  be  loosely  rolled,  and  the  powdered  plaster 
worked  in  with  the  hands  so  well  and  thoroughly  that  the  meshes  of  the 
cloth  can  not  be  seen.  Considerable  experience  is  required  to  prepare  a 
good  plaster  bandage,  and  a  poor  one  will  spoil  a  dressing.  Plaster  band- 
ages should  be  made  from  fresh  gypsum  on  the  day  they  are  to  be  ap- 
plied. Cotton  and  flannel  bandages  should  be  kept  in  a  chest  or  closet 
away  from  dast  and  moisture. 

Methods  of  applying  Bandages. — The  various  portions  of  the  body 
may  be  bandaged  by  the  simple  spiral.,  reverse  spiral.,  simple  figure- of -8., 
and  the  figure-of-8  reverse. 

The  simple  spiral  turn  is  most  useful  in  bandaging  those  parts  of  the 
body  where  there  is  no  sudden  increase  in  the  diameter  and  volume  of  the 
part.     It  is  impracticable  under  other  circumstances. 

Hold  the  bandage  in  the  hand  most  convenient,  with  the  back  of  the 
roller  toward  the  limb  (see  Fig.  12) ;  with  the  unoccupied  hand  take  the 


free  end  of  the  bandage,  lay  and  hold  it  upon  the  inner  border  of  the 
limb,  and  carry  the  turn  by  the  front  to  the  outer  side  of  the  part  to  be 
bandaged. 

Having  carried  the  roUer  twice  around  the  part  to  secure  it,  ascend  the 
limb  spiraUy,  leaving  about  one  thii'd  of  each  turn  uncovered  by  the  last. 


12 


A  TEXT-BOOK  ON  SURGERY. 


m 


The  reverse-spiral  turn  (Fig.  13)  is  applied  as  follows  : 

Taking  the  left  arm  to  be  bandaged,  hold  the  roller  in  the  right  hand, 
with  its  convexity  toward  the  limb,  and  carry  it  from  the  inner  or  ulnar 
border,  by  the  front,  to  the  outer  or  radial  border,  and  thus  around  the 
arm  by  two  circular  turns  to  secure  the  roller.  Then,  having  carried  the 
bandage  to  the  outer  side,  ascending  the  limb  gradually,  lay  the  thumb 
of  the  left  hand  upon  the  lower  edge  of  the  bandage,  press  it  firmly 
against  the  limb  to  prevent  slipping,  loosen  the  roller  considerably  in  the 
right  hand,  at  the  same  time  tui'ning  it  one-half  turn  toward  the  operator. 
This  process  is  to  be  repeated  as  often  as  necessary,  keeping  the  reverses 
well  upon  the  outer  border  and  anterior  aspect  of  the  extremity. 

The  Simple  Figure  -  of-  8 
Turn. — After  the  bandage  is  se- 
cured, as  heretofore  described, 
ascend  the  limb  sharply,  from 
the  inner  to  the  outer  border, 
so  that  at  this  outer  border  the 
lower  edge  of  the  roller  shall  be 
several  inches  above  the  start- 
ing-point. Carry  the  roller  di- 
rectly across  and  behind  the 
limb  to  the  same  point  on  the  / 

opposite  side ;  then  obliquely  / 
downward  in  front,  crossing  the 
ascending  turn  at  a  right  angle. 
When  the  outer  border  is  again 
reached,  carry  the  roller  behind 
and  directly  across  the  limb  to 
the  starting-point  (see  Fig.  14). 

The  Figure- of -8  Reverse. — 
Commence  exactly  as  for  the 
simple  figore-of-8  until  the  band- 
age has  passed  across  the  pos- 
terior aspect  of  the  limb,  and 
is  about  to  descend  obliquely 
along  the  inner  aspect  to  the  front.  With  the  index-finger  of  the  unoc- 
cupied hand  hold  the  lower  edge  of  the  bandage  tightly  against  the  part, 
while  the  roller  is  slackened  and  turned  half  over  in  a  direction  away 
from  the  limb.  This  reverse  in  the  figure-of-8  may  also  be  made  ante- 
riorly, and,  when  the  conformation  of  the  part  demands  it,  may  be  made 
both  anteriorly  and  posteriorly. 

Of  these  four  methods,  the  simple  spiral  is  more  readily  applied. 
When  the  diameter  of  the  extremity  increases  rapidly  it  will  not  suflBce, 
since  it  grasps  the  part  at  the  upper  edge  of  the  roller  while  the  lower 
stands  out  free  and  loose. 

For  all  purposes  the  spiral  reverse  is  more  generally  useful.  In 
competent  hands  it  can  be  applied  to  all  portions  of  the  body  except 
where  the  members  join  the  trunk,  when  it  must  give  place  to  the  simple 


Fig.  14.— The  figure-of-8  method. 


BANDAGING. 


13 


Jigure-of-8  turn.  Thus,  tlie  spica  at  the  groin  and  shoulder,  the  occiput 
and  chin  dressings,  and  the  neck  and  shoulder  bandages,  must  describe 
this  shaj)e.  The  flgure-of-8  reverse  is  of  great  use  in  getting  over  the  calf 
of  the  leg  in  very  muscular  subjects,  where  not  infrequently  all  the  other 
methods  "noLL  fail  to  hold. 

The  important  rule  in  bandaging  is  to  equalize  the  pressure  from 
periphery  to  center.  The  cii-cum stances  of  the  case  will  determine  the 
degree  of  compression.  It  requires  a  great  deal  of  study  and  practice  to 
become  expert  in  applying  dressings.  One  should  thorouglily  familiarize 
one's  self  with  each  of  the  methods,  for  not  infrequently  a  part  to  be 
dressed  wUl  require  a  combiuation  of  several  methods.  The  question  of 
how  tight  to  apply  the  bandage  may  in  part  be  left  to  the  sense  of  the 
jjatient  when  an  anesthetic  is  not  employed.  After  an  extensive  opera- 
tion, in  which  Esmarch's  bandage  has  been  applied,  a  very  considerable 
degree  of  compression  is  often  required  to  prevent  the  oozing  which 
otherwise  would  follow  the  use  of  this  tourniquet.  No  amount  of  de- 
scription will  impart  this  sense  to  the  inquirer ;  it  can  only  come  fi'om 
personal  experience.  One  precaution  is  imperative  :  the  tips  of  the  fin- 
gers or  toes  of  the  extremity  bandaged  must  always  be  left  open  for 
observation,  for  if  strangiTlation  is  threatened  it  will  always  be  earliest 
indicated  here.     A  watch  should  be  set  on  every  case  where  there  is 

ground  for  anxiety,  with  direc- 
tions to  slit  the  dressing  with  the 
appearance  of  any  symptom  of 
strangulation. 

Special  Bandages — The  Hand 
and  Fingers  hy  the  First  Method 
(Fig.  15). — Take  a  roller  between 
three  fourths  and  one  inch  in 
width,  and  ten  yards  in  length. 
Let  the  hand  to  be  bandaged  be 
pronated,  and  commence  by  tak- 
ing two  or  three  turns  of  the  roller 
around  the  carpus,  going  from  the 
radial  over  the  back  of  the  wrist 
to  the  ulnar  side.  Having  iu  this 
manner  secured  the  roller,  carry  it 
fi'om  the  radial  side  of  the  wrist 
obliquely  across  the  dorsum  of  the 
hand  to  the  ulnar  border  of  the 
root  of  the  little  finger,  then  spi- 
rally around  the  little  finger  two 
turns  to  its  extremity.  Next,  re- 
turn by  careful  spiral  turns,  or  a 
spu'al  reverse,  if  necessary,  to  the 
root  of  the  finger,  covering  it  equal- 
ly and  nicely.  From  the  radial  border  of  the  base  of  the  finger  the  band- 
age is  carried  over  the  back  of  the  hand  to  the  ulnar  side  of  the  carpus, 


Fig.  15. — Hand-,  thumb-,  and  finger-bandage.    (The 
author's  modification  of  tbe  old  method.) 


14 


A   TEXT-BOOK   ON   SURGERY. 


then  under  tlie  wrist,  by  the  front,  to  the  radial  side,  and  again  over  the 
dorsum  of  the  hand  around  to  the  ulnar  side  of  the  same  finger,  repeat- 
ing the  figure-of-8,  as  before.  Two  turns  are  then  thrown  around  the 
wrist  to  secure  the  former  bandage,  and  the  roller  is  carried  in  the  same 
manner  to  the  remaining  fingers. 

When  the  index-finger  is  reached,  on  account  of  the  great  space  be- 
tween its  root  and  the  thumb,  it  is  advisable  to  make  four  or  five  extra 
figure-of-8  turns  around  its  base,  carrying  the  bandage  a  little  lower  with 
each  successive  layer  toward  the  thumb. 

Having  reached  the  thumb,  the  roller  is  carried  spirally  to  its  ex- 
tremity, as  in  the  other  fingers,  but  in  returning,  when  the  last,  the  in- 
terphalangeal,  joint  is  reached,  the  figure-of-8  turn  is  commenced  at  this 
point,  and  continued  until  the  ball  of  the  thumb 
is  completely  covered. 

This  method  may  be  applied  to  the  thumb 
alone,  or  to  any  one  or  more  of  the  fingers,  when 
the  remainder  of  the  hand  does  not  need  to  be 
bandaged,  and  is  equally  efiicient  in  securing 
splints  to  these  organs. 

One  objection  to  it,  and  a  very  formidable  one 
to  the  practitioner,  is  the  length  of  time  necessary 
to  apply  it.  A  more  rapid  and  almost  equally 
effective  way  is  the  hand-bandage  by  the  second 
method  (Fig.  16). 

Place  pellets  of  cotton  between  the  fingers,  and 
a  fair-sized  tuft  in  the  palm  of  the  hand.  Take  a 
bandage  from  one  to  two  inches  in  width,  carry 
it  one  or  two  turns  around  the  hand  where  the 
phalanges  join  the  metacarpus,  until  it  is  secured, 
and  then  by  nicely  adjusted  figure-of-8  turns  (the 
crossings  on  the  dorsal  aspect  of  the  fingers)  cover 
the  hand  from  the  tips  of  the  fingers  back.  When 
the  bandage  reaches  the  thumb  in  the  crotch  be- 
tween it  and  the  index,  and  begins  to  roll  up,  it 
should  be  clipped  with  the  scissors  deeper  and 
deeper  along  the  edge  nearest  the  thumb  with  fig.  le. 

each  successive  turn  until  the  cut  extends  to  the 

middle  of  the  roller.  Then  a  split  should  be  made  in  the  middle  parallel 
with  its  long  axis,  and  the  thumb  stuck  through  this  ;  the  next  split  is 
nearer  the  distal  edge,  while  with  the  succeeding  turn  it  may  be  brought 
clear  of  the  thumb  on  its  carpal  aspect.  A  spiral,  with  or  without  the 
reverse,  will  hold  on  the  incline  from  the  thumb  to  the  carpus. 

The  Forearm,  Arm,  and  Shoulder. — From  the  carpus  to  the  elbow 
the  spiral  reverse  or  figure-of  8  will  usually  be  required,  on  account  of 
the  pyramidal  shape  of  the  part.  When  the  elbow  is  reached,  if  the 
right-angle  position  (Fig.  17)  is  determined  upon,  the  figure-of-8  around 
the  humerus  and  forearm  will  suflace  to  climb  along  the  elbow ;  or  the 
simple  spiral,  carried  over  the  same  ground  in  the  flexure  of  the  joint,  and 


BANDAGING. 


15 


gi-aduaUy  ascending  over  the  convexity,  will  accomplish  the  same  pur- 
pose.   For  the  arm  the  spiral,  simple  or  reverse,  will  carry  the  bandage  to 

the  axilla.  When  the 
projection  caused  by  the 
tendon  of  the  pectoralis 
major  is  reached,  the 
roller  is  carried  from  the 
inner  side  by  the  front, 
over  the  point  of  the 
shoulder,  around  the 
back,  and  underneath 
the  opposite  arm,  across 
the  chest  to  the  anterior 
and  outer  surface  of  the 
liumerus,  then  under- 
neath the  arm,  making 
a  fignre-of-8  turn,  one 
loop  of  which  surrounds 
the  arm,  and  the  other 
the  thorax.  These  turns 
are  continued,  gradually 
ascending  until  the  root 
of  the  neck  is  reached. 
^»-  1^-  It  is  best  to  fill  the  ax- 

illa of  both  arms  with 
absorbent  cotton  to  prevent  chafing,  when  this  di'essing  is  to  be  worn  for 
any  length  of  time. 

Tlie  Toes,  Foot,  Leg,  and  Thigh. — The  great  toe  may  be  bandaged 
by  carrying  a  narrow  roller  spirally  around  it,  fi'om  the  tijp  to  the  meta- 
tarso-phalangeal  joint,  and 
thence  by  a  figure-of-8 
around  the  ankle.  This 
last  turn  should  be  sev- 
eral times  repeated,  in  or- 
der to  hold  the  dressing 
firmly.  It  is  ciistomary  to 
include  all  of  the  toes  in 
the  general  foot-bandage. 
To  bandage  the  foot, 
begin  by  jjlacing  bits  of 
absorbent  cotton  between 
the  toes.  Take  a  roller 
from  two  to  two  and  a  half 
inches  wide,  and  about 
ten  yards  long.     Lay  the 

end  of  the  bandage  parallel  with  the  axis  of  the  leg,  half-way  between 
the  two  malleoli  in  front,  and  carry  the  roller  by  the  inner  side  to  the 
heel,  so  that  the  middle  of  the  bandage  will  be  over  the  center  of  the 


Fig.  is. — The  author's  foot-bandaire  "svith  a  single  roller. 


16 


A  TEXT-BOOK   ON   SURGERY. 


heel's  convexity,  and  on  to  the  starting-point.  Next,  make  another  turn 
around  the  ankle,  carrying  the  posterior  edge  of  the  bandage  over  the 
center  of  the  turn  that  lias  just  preceded  it,  and  mal^e  one  or  two  other 
turns  in  front  of  this  until  the  heel  is  completely  covered  (Fig.  18). 

The  bandage  is  then  carried  around  the  heel  in  the  same  direction,  so 
that  its  anterior  border  rests  on  the  middle  of  the  first  turn,  and  the 
roller  is  carried  from  the  fibular  side  of  the  heel  across  the  dorsum  of  the 
foot  to  the  tibial  side  of  the  great  toe. 
It  then  travels  under  the  bases  of  the 
toes  to  the  little  toe,  making  a  couple  of 
complete  turns  around  the  foot  at  this 
point,  and,  when  the  roller  has  again 
reached  the  fibular  side  of  the  little  toe, 
it  is  made  to  cross  the  dorsum  of  the 
foot  obliquely  to  the  tibial  side  of  the 
heel,  keeping  the  lower  edge  of  the  band- 
age about  a  quarter  of  an  inch  above  the 
bottom  of  the  heel.  Repeat  this  figure- 
of-8  turn  until  the  entire  foot  is  thor- 
oughly concealed.  It  is  best  to  cut  with 
the  scissors  each  turn  of  the  roller  about 
half  through  just  when  it  crosses  the 
front  of  the  ankle,  so  that  the  accumu- 
lation of  the  bandage  at  this  point  may 
not  interfere  with  the  movements  of  the 
ankle-joint. 

The  crossings  of  the  figure-of-8  band- 
age on  the  dorsum  of  the  foot  should  be 
kept  a  little  to  the  fibular  side  of  the 
median  line. 

When  the  ankle  is  reached,  the  band- 
age should  be  carried  up  the  leg  by  the 
spiral  reverse  until  the  sudden  promi- 
nence of  the  muscles  of  the  calf  is 
reached,  when,  if  necessary,  the  figure- 
of-8  reverse  should  be  practiced  to  just 
below  the  knee.  From  this  point  up  to 
the  trochanter  the  simple  figure-of-8,  spi- 
ral, or  spiral  reverse,  may  be  employed,  ^"o-  19- 
according    to    the    shape   of    the    limb. 

When  the  level  of  the  gluteal  fold  is  reached,  carry  the  roller  obliquely 
upward  and  outward  about  half-way  between  the  trochanter  major  and 
anterior  iliac  spine,  on  across  the  sacro-lumbar  region  to  just  above  the 
upper  margin  of  the  iliac  crest  of  the  side  opposite  the  limb  being  band- 
aged, thence  downward  across  the  abdomen  and  the  groin  to  the  front 
and  outer  side  of  the  thigh,  and  back  behind  to  the  inner  side  at  the 
point  of  starting.  This  manoeuvre  is  repeated  until  the  entire  hip  and 
groin  are  covered,  when  the  roller  is  carried  spirally  around  the  pelvis 


BANDAGING. 


17 


and  abdomen  as  Mgli  as  the  Timbilicns.  The  completed  bandage  is  shown 
in  Fig.  19.  The  portion  of  this  bandage  which  goes  around  the  thigh, 
groin,  and  pelvis  is  called  the  single  spica  for  the  groin,  and  is  admira- 
bly adapted  to  the  retention  of  a  dressing  upon  a  bubo  or  wound  of 
this  region,  and  also  makes  an  efficient  temporary  compress  for  the  sup- 
port of  an  inguinal  hernia.  A  double  spica  with  a  single  roller  may  be 
made  by  carrying  the  roller,  which  has  ah-eady  partially  covered  in  the 
groin  and  hip  of  one  side,  directly  across  the  back  to  a  point  half-way 
between  the  trochanter  and  anterior  iliac  spine  of  the  opposite  side,  over 
the  front  of  the  thigh  to  the  inner  side,  and  tlience  behind  and  outward, 
describing  a  ligure-of-8  around  the  thigh  and  pelvis  in  a  direction  the 
reverse  of  the  preceding  (Fig.  20). 

The  abdomen  and  thorax  should  be  bandaged  by  the  simple  or  re- 
verse spiral  until  the  axilla  is  reached  in  the  male,  and  the  mammary 
gland  in  the  female. 


Fig.  20.— (After  Fiscter.) 


To  bandage  the  mammary  gland  it  is  best  to  ]olace  a  thin  layer  of 
absorbent  cotton  over  this  organ,  and  under  the  axilla  as  well.  The 
roller,  about  three  inches  wide,  should  be  carried  two  or  thi-ee  times 
around  the  thorax  just  below  the  breast,  which,  if  pendiilous,  should  be 
lifted  well  up  toward  the  clavicle.  If  the  right  breast  is  to  be  bandaged, 
the  operator,  standing  in  front,  should  caiTy  the  roller  from  the  patient's 
right  to  the  left  side,  around  the  body,  and  then  obliquely  u^Dward  across 
the  front  of  the  chest,  catching  the  under  surface  of  the  gland,  passing  over 
the  left  clavicle,  making  a  figure-of-8  around  the  shoulder  and  axilla,  and 
then  across  the  back  to  the  starting-point  (see  Fig.  21).  It  is  now  carried 
directly  around  the  chest,  and,  when  the  circuit  is  completed,  again  travels 
obliquely  upward  on  a  plane  about  one  inch  higher  than  the  preceding 
turn.  This  is  repeated  until  the  organ  is  entirely  covered.  When  both 
2 


18 


A  TEXT-BOOK   ON   SURGERY. 


Fig.  22.— (After  Fischer.) 


breasts  require  support,  the  second  may  be  bandaged  in  the  same  way  by 
an  additional  roller,  or,  as  shown  in  Fig.  22,  a  single  bandage  may  be 
thrown  around  the  thorax  and  neck  in  fig- 
tire-of-8  fashion,  so  as  to  support  both 
organs. 

Bandages  for  the  Head  and  Face. — 
For  retaining  ice-caps,  or  other  dressings 
to  the  head,  the  hood-bandage  will  be 
found  convenient,  while  its  modifications 
will  sufiice  to  keep  a  dressing  upon  any 
limited  portion  of  the  scalp  (Fig.  23). 

To  apply  this,  take  a  roller  twelve  yards 
long  and  two  and  a  half  inches  in  width, 
rolled  from  both  ends  to  the  center.  Hold- 
ing one  head  of  the  roller  in  each  hand,  the 
surgeon,  standing  behind  the  patient  and 
laying  the  middle  of  the  bandage  across 
the  forehead  just  over  the  eyebrows,  car- 
ries one  roller  in  the  right  and  the  other 
in  the  left  hand  around  the  head,  above 

the  ears,  and  crosses*  them  under  the  occiput,  so  that  the  roller  which 
went  to  the  rear  in  the  left  hand  will  travel  again  to  the  front  over  the 
same  path.  The  roller  in  the  right  hand  is  then 
carried  over  the  head,  in  the  median  line,  from  the 
occiput  to  the  nose,  and  at  this  point  it  is  caught 
and  held  down  by  the  encircling  turn  carried  in 
the  left  hand.  Then  carry  the  roller  which  came 
over  the  median  line  of  the  head  back  again  to  the 
rear,  so  that  its  right  edge  will  rest  on  the  middle 
of  the  first  turn.  It  is  again  caught  under  the 
encircling  turn  at  the  occiput,  is  carried  to  the 
front  on  the  opposite  side,  and  continues  to  travel 
from  before  backward  in  an  ellipse  that  is  con- 
stantly increasing,  until  it  blends  with  the  encir- 
Fis.  23.  cling  turn  upon  the  sides  of  the  head,  near  the 

ears.  Each  successive  turn  of  the  elliptic  should 
leave  about  one  third  of  the  turn  that  preceded  it  uncovered  in  the  cen- 
ter. Of  course,  the  ends  will  meet  at  the  same  point,  before  and  behind, 
where  the  reverses  are  made. 

If  it  is  only  required  to  maintain  a  dressing  in  the  median  line  of  the 
scalp,  it  will  sufiice  to  carry  a  circular  turn  or  two  around  the  head,  Jiist 
above  the  eyebrows  and  ears,  and  below  the  occiput,  while  an  antero- 
posterior strip  is  pinned  to  this  in  front  and  behind. 

The  Head  and  Chin  Bandage  (Fig.  24)  may  be  made  to  serve  sev- 
eral purposes— namely,  to  retain  a  dressing  on  the  chin  and  lower  face, 
the  same  upon  the  scalp  at  any  portion,  and  also  for  temporary  fixa- 
tion of  the  lower  jaw  after  fracture  of  this  bone.  It  is  applied  as 
follows : 


BANDAGING. 


19 


The  end  of  a  bandage  from  one  inch  and  a  half  to  two  inches  in  width 
is  held  about  half-way  between  the  left  ear  and  the  occipital  protuber- 
ance, while  the  roller  is  carried  to  the  front  and  obliquely  across  the 
head,  just  in  front  of  the  right  ear,  under  the  chin,  up  in  front  of  the 
left  ear,  then  across  the  scalp,  passing  backward  between  the  right  ear 
and  occiput  to  beneath  this  protuberance,  when  it  is  carried  beneath  the 
left  ear  straight  across  the  front  or  labial  aspect  of  the  chin,  and  around 
by  the  right  side  to  the  point  of  commencing.  This  manoeuvre  should 
be  repeated  several  times,  and  the  dressing  then  completed  by  carrying 
the  roller  twice  around  the  head  above  the  ears  and  eyebrows,  and  be- 
neath the  occiput,  and  pinniag  a 
strip  along  the  median  line  of  the 
scalp  at  the  various  points  where 
the  turns  ci-oss  each  other. 

Knotted  Bandage. — This  dress- 
ing   (Fig.   25)    is  sometimes  em- 


FiG    25  —(Alter  Berkeley  Hill.) 


ployed  in  the  arrest  of  heemorrhage  from  wounds  of  the  temporal  and 
other  vessels  of  the  scalp. 

Take  a  piece  of  cork  or  wood,  about  an  inch  in  diameter  and  one 
quarter  of  an  inch  in  thickness,  and  wrap  it  with  sublimate  gauze  or 
lint  to  make  a  compress.  Apply  this  to  the  bleeding  point,  and  lay  over 
it  the  center  of  a  double-headed  roller,  carrying  the  turns  around  the 
head,  above  the  ears.  They  are  then  crossed  over  the  compress,  one  end 
is  carried  under  the  chin,  the  other  over  the  top  of  the  head,  and  are 
again  crossed  on  the  opposite  temple.  Having  carried  the  rollers  again 
around  the  head,  and  crossed  them  firmly  over  the  compress,  the  ends 
are  pinned  securely  and  cut  off.  A  horizontal  slip  may  then  be  pinned 
to  the  anterior,  middle,  and  posterior  slips  of  the  knotted  bandage,  be- 
ginning in  the  median  line  on  the  forehead,  then  back  to  the  center  of 
the  middle  slip,  and  then  to  the  slip  underneath  the  occiput,  to  hold  the 
dressing  securely  in  position. 

To  bandage  the  eye  (the  left,  for  example),  hold  the  end  of  the  strip 
half-way  between  the  right  ear  and  occiput,  and  bring  the  roller  forward 
over  the  left  eye  and  malar  eminence,  and  around  backward  beneath  the 
ear  and  occiput  to  the  point  of  starting,  and  repeat  once.  When  the 
second  turn  arrives  at  the  right  ear  it  should  pass  above  this  and  com- 


20 


A  TEXT-BOOK   ON   SURGERY. 


pletely  around  the  skull,  just  above  the  eyebrows  and  below  the  occiput, 
in  order  to  secure  the  oblique  turn.  Complete  the  dressing  by  alternating 
between  the  horizontal  and  the  oblique  direction  of  the  roller  (Fig.  26). 

For  the  upper  lip  a  dressing  is 
readily  secured  by  a  narrow  band- 
age passing  horizontally  around 


Fig.  26.— (After  Esmarch.) 


beneath  the  nose  and  ears,  and 

held  in  place  by  the  head-stall  fig.  27. 

attachment,  as  in  Fig.  24. 

Handker chief  Bandages. — In  addition  to  the  foregoing,  emergency 
dressings  for  different  parts  of  the  body  may  be  extemporized  from  pieces 
of  cloth  cut  in  various  shajjes — the  so-called  handkerchief  bandages. 

Head  and  Face. — A  simple  hood  (Fig.  27)  may  be  made  as  follows : 
A  piece  of  soft  muslin  is  cut,  27  by  23  inches,  folded  over  for  6  or  7  inches 
along  its  greatest  measurement,  and  laid  upon  a  table,  with  the  short  piece 
underneath.  Place  the  index-finger  at  the  middle  of  the  folded  edge, 
and  turn  the  nearest  corners  toward  the  center,  forming  a  pyramid.  Now 
roll  the  remaining  straight  edge  np  until  it  is  on  a  level  with  the  edge 
which  was  turned  under,  and  place  upon  the  head,  so  that  this  edge  will 
be  put  above  the  eyebrows,  while  the  rolled  portion  comes  across  the 
occiput,  and  the  ends  are  jjinned  beneath  the 
chin.  The  conical  tip  may  be  pinned  down,  if 
desired. 

The  four-tailed  cap  is  made  from  a  piece  of 
muslin,  45  inches  long  by  10  wide,  split  from 
each  end  to  within  4  inches  of  the  center.  Each 
of  the  four  tails  is  5  inches  in  width.  Lay  the 
center  of  the  piece  across  the  vertex,  carry  the 
posterior  tails  forward  over  the  ears,  and  tie 
them  under  the  chin  and  the  anterior  backward 
beneath  the  occiput  (Fig.  28). 

The  head  and  face  hood  is  made  as  follows : 
A  piece  of  soft,  light  cloth,  40  inches  square,  is 


BANDAGING. 


21 


folded  and  laid  across  the  liead  in  such,  a  manner  that  the  shortest  fold 
which  is  on  top  comes  to  the  level  of  the  eyebrows,  while  the  longer 
reaches  to  the  tip  of  the  nose  (Fig.  29).     The  corners  belonging  to  the 


Fig.  30.— (After  Estnarcli.) 

fold  which  is  parallel  with  the  line  of  the  eyebrows  are  tied  snugly  be- 
neath the  chin.  The  longer  fold  is  now  turned  up  to  the  level  of  the 
eyebrows,  while  the  corners  belonging  to  it  are  drawn  forward  until 
freed,  and  are  then  carried  back  and  tied  beneath  the  occiput  (Fig.  30). 
For  holding  an  ice-bag  or  dressing  upon  the  head,  the  skull-net 
(Fig.  31)  wiU  be  found  of 
use.  It  is  made  of  cot- 
ton threads,  is  tightened 
around  the  head  by  a 
tape,  which  draws  it  to- 
P"-^^S!^^^S^S"/v}^  gather  like  the  strings  of 
fe  ^t^^^^HBltlf  ^  reticule,  and  is  further 
secured  by  a  strap  tied 
under  the 'chin. 

The  four-tailed  dress- 
ing for  tJie  chin  and  low- 
er jaw  is  made  by  split- 
ting a  strip  of  muslin,  6 
inches  wide  and  45  inches 
long,    from   each  end  to  Fig.  ss. 

within  1^  inch  of  the  cen- 
ter, placing  its  middle  over  the  chin,  and  turning  the  posterior  tails  up- 
ward in  front  of  the  ears  to  be  tied  over  the  vertex.  The  anterior  tails 
are  now  carried  back  below  the  ears,  crossed  once,  and  pinned  beneath 
the  occiput,  while  the  ends  are  carried  upward  and  forward  and  tied 
upon  the  forehead  (Fig.  32). 

Other  special  dressings  will  be  described  in  the  chapters  on  Regional 
Surgery. 


Fig.  31.— (After  Esmarch.) 


CHAPTER  III, 

ANESTHESIA. 

Anesthesia  means  loss  of  sensibility.  It  may  be  local  or  general. 
In  the  former,  the  sensibility  of  a  limited  portion  of  the  body  is  more  or 
less  completely  lost,  while  the  patient  remains  conscious  ;  in  the  latter, 
both  consciousness  and  sensibility  are  lost. 

Local  anaesthesia  may  be  obtained  in  a  remarkable  degree  by  the  judi- 
cious employment  of  the  hydrochlor'ate  of  cocaine,  for  the  application  of 
which  agent  to  surgical  use  the  world  will  ever  be  indebted  to  the  Austrian, 
Koller.  The  2-  and  4-per-cent  solutions  are  chiefly  used.  An  aseptic  solu- 
tion may  be  made  by  employing  gr.  j  boric  acid  to  3  j  of  distilled  water. 
To  this  add  gr.  xx  hydrochlorate  of  cocaine,  which  is  approximately  a  4- 
per-cent  solution.  Applied  to  the  cornea,  conjunctiva,  or  any  mucous  sur- 
face, cocaine  is  rapidly  absorbed,  the  capillaries  are  contracted,  and  the 
end  organs  of  the  sensory  nerves  paralyzed.  Upon  the  unbroken  integu- 
ment it  produces  little  or  no  effect.  Injected  into  the  tissues,  it  produces 
anaesthesia  wherever  it  reaches — in  bone,  muscle,  or  the  subcutaneous 
structures.  Thrown  into  the  substance  of  a  nerve,  or  immediately  around 
it,  it  is  readily  absorbed,  and  produces  anaesthesia  in  all  parts  in  the 
range  of  distribution  of  the  nerve-trunk  beyond  the  point  of  injection. 
The  quantity  which  can  be  safely  used  has  not  yet  been  determined,  and 
must  vary  with  the  susceptibility  of  the  individual.  Applied  to  the  eye, 
there  is  no  danger  of  absorption  of  a  quantity  capable  of  doing  harm. 
Upon  the  mucous  surfaces  of  the  buccal  cavity  and  pharynx  several 
drachms  of  a  4-per-cent  solution  may  be  brushed  with  a  camel's-hair 
pencil  in  the  course  of  an  operation  lasting  an  hour,  for  here  the  excess 
is  washed  off  and  diluted  with  the  saliva,  which,  of  course,  should  not  be 
swallowed.  Injected  into  the  deeper  tissues,  below  the  face  and  neck, 
from  twenty  to  thirty  minims  of  a  4-per-cent  solution  should  be  the  limit 
within  at  least  one  hour  before  the  dose  is  repeated,  unless  a  good  pro- 
portion of  the  liquid  injected  is  allowed  to  escape  by  immediately  incising 
in  the  line  of  injection.  Within  the  distribution  of  the  fifth  nerve  its 
administration  should  be  especially  cautious.  Partial  respiratory  paraly- 
sis has  occurred  in  several  instances  after  the  injection  of  fifteen  minims 
of  a  4-per-cent  solution  in  the  supra-orbital  region,  and  in  other  portions 
of  the  face.  Artificial  respiration  was  necessary  for  about  fifteen  minutes. 
Chloroform  or  ether  narcosis  is  believed  to  be  unusually  dangerous  while 
a  patient  is  under  the  influence  of  cocaine. 


ANESTHESIA,  23 

For  the  eye,  drop  two  or  three  minims  of  a  4-per-ceiit  solution  into  this 
organ  every  minute  or  two,  until  fi'om  five  to  ten  minutes  have  elapsed 
For  light  work,  such  as  the  removal  of  a  foreign  body,  or  touching  the 
lids  with  blue-stone,  the  smaller  quantity -v\-i]l  suifice  ;  for  corneal  section, 
iridectomy,  etc.,  the  anaesthesia  should  be  more  profound.  In  the  mouth, 
it  wUl  sufEce  to  paint  the  part  to  be  antesthetized  with  the  4-per-cent  so- 
lution bj'  means  of  a  camel's-hair  brush,  every  two  or  three  minutes,  for 
a  half-hoiu'  before,  and  at  intervals  during  the  operation.  In  this  way 
ulcers  may  be  cauterized,  or  limited  incisions  made  with  perfect  insensi- 
bility, and  by  the  employment  of  this  agent  any  irritable  condition  of  the 
mouth  and  throat  may  be  relieved.  I  have  ojierated  for  cleft  of  the  soft 
palate  in  an  adult  ^vith  perfect  antesthesia  by  this  method. 

In  minor  surgical  operations  upon  the  extremities,  a  prolonged  and 
perfect  anfesthesia  may  be  secured  by  the  method  of  Corning,  which  con- 
sists in  injecting  the  fluid  into  the  tissues  of  the  part  to  be  antesthetized, 
waiting  from  two  to  five  minutes  for  absorption  of  the  solution  by  the 
vessels,  and  then  keeping  the  cocaine  in  the  tissues,  by  arresting  the  cir- 
culation, with  a  rubber  tourniquet  applied  between  the  injection  and  the 
heart.  The  efiiciency  of  this  method  has  been  amply  demonstrated.  The 
twenty  or  thirty  minims  of  4-per-cent  solution  should  be  distributed  equal- 
ly in  the  line  of  the  incision.  A  single  puncture  with  the  hypodermic 
needle  will  sufiice  to  allow  the  fluid  to  be  thrown  over  an  area  an  inch  in 
length,  and  the  effect  is  so  rajAd  that  the  second  puncture  can  be  made 
through  the  anaesthetized  skin.  The  needle,  after  passing  thi'ough  the 
integument,  travels  along  just  beneath  it  to  its  full  length.  One  or  two 
minims  are  then  forced  out,  the  needle  withdrawn  a  quarter  or  half  inch, 
and  a  like  quantity  discharged.  If  a  deep  incision  is  required,  the  needle 
should  go  into  the  deej^er  tissues.  One  advantage  of  this  method  is  that 
a  smaller  quantity  of  cocaine  'nill  produce  a  greater  degree  of  anaesthesia, 
and  with  less  constitutional  effect.  "When  as  much  as  thirty  minims  are 
used,  the  excess  may  be  squeezed  or  pressed  out  of  the  part,  or  washed 
out  with  the  irrigator.  As  to  the  length  of  time  for  which  a  tourniquet 
may  safely  remain  holding  the  part  beyond  fuU  of  stagnant  blood,  I  would 
say  that  a  half -hour  would  be  within  the  limit  of  safety.  I  have  con- 
stricted the  iDenis  continuously  for  an  hour  in  circumcision,  the  great  toes 
on  several  occasions  for  more  than  half  an  hour  in  removing  ingrowing 
nails,  and  the  arm  for  half  an  hour  in  a  number  of  cases.  It  is,  however, 
not  always  necessary  to  entirely  arrest  the  circulation  of  a  part,  for,  if  the 
elastic  be  applied  close  behind  the  part  to  be  incised,  the  superficial  com- 
pression mil  retard  the  flow  at  this  point,  while  the  deeper  vessels  and 
remote  capillaries  are  not  materially  interfered  with. 

In  minor  operations  upon  the  trunk,  face,  head,  and  neck,  greater  pre- 
caution must  be  taken,  for  here  the  solution  is  carried  directly  to  the  center. 
This  is  especially  necessary  in  the  head  and  face,  for  reasons  above  given. 

If  the  i^recaution  is  taken  to  throw  in  a  small  quantity — say  five  or  ten 
minims — in  the  line  of  the  proposed  dissection,  and  immediately  incise  and 
dissect  as  far  as  the  zone  of  anaesthesia  extends,  so  much  of  the  injected 
cocaine  escapes  with  the  oozing  that  comparatively  a  small  proportion 


24 


A  TEXT-BOOK   ON  SUKGERY. 


passes  into  the  general  circulation.  By  tMs  practice  I  have  made  a  great 
many  operations  requiring  3  j-ij  of  a  4-per-cent  solution  without  acci- 
dent. The  details  to  be  observed  in  special  operations,  such  as  ampu- 
tation of  a  finger  or  toe,  circumcision,  extirpation  of  ingrowing  toe- 
nails, etc.,  will  be  given  under  the  headings  to  which  these  various  pro- 
cedures belong. 

Another  method  of  producing  local  anaesthesia  is  by  means  of  ether 
sprawl/.  For  this  purpose  the  ordinary  Richardson's  atomizer  (Fig.  33) 
will  suffice.  In  purchasing  this  apparatus,  secure  one  with  a  silver  tube — 
not  of  glass,  for  this  is  too  fragile,  nor  of  gutta-percha,  which  is  always 
getting  stopped  up.  The  atomization  of  the  ether,  and  the  consequent 
rapid  evaporation,  produces  an  intense  cold,  retards  temporarily  the  capil- 
lary circulation,  and  thus  paralyzes  the  end  organs  of  the  sensory  nerves. 
Everything  being  in  readi- 
ness, an  assistant  commences 
the  atomization,  holding  the 
end  of  the  tube  from  three  to 
six  inches  distant  from  the 
skin,  so  that  the  shower  of 
vapor  will  fall  upon  the  area 
to  be  incised.  The  skin  un- 
der the  spray  changes  from 
the  normal  flush  to  a  whitish 
purple,  which,  by  a  continu- 
ation or  sudden  increase  of 
the  force  of  the  spray,  will 

turn  white  and  become  stiff  and  frozen.  This  last  condition  is  to  be  avoid- 
ed in  general,  for  the  reaction  from  it  is  painful  and  sloughing  may  occur, 
while  a  sufficient  ansesthesia  may  be  obtained  without  real  freezing.  When, 
by  pinching  Avith  the  forceps  or  pricking  with  the  knife,  insensibility  is 
assured,  the  operation  should  begin,  and  the  spray  be  continued.  Ether 
spray  can  not  be  emj)loyed  about  the  eye,  on  account  of  the  irritation  it 
produces,  nor  about  the  nose  and  mouth,  on  account  of  its  being  inhaled. 
It  is  in  general  inferior  to  cocaine  ansesthesia,  because  the  latter  secures 
a  more  complete  insensibility,  and  the  reaction  is  far  less  painful.  Jihi- 
goline  may  be  used  instead  of  ether,  but  it  is  so  difficult  to  obtain  that  it 
has  been  superseded  by  the  ether. 

A  mixture  of  equal  parts  of  cracked  ice  or  snow,  and  salt,  applied 
directly  to  a  part  or  wraj^ped  in  a  thin  cloth  and  laid  upon  the  skin,  will 
produce  perfect  local  ansesthesia,  and  is  a  fair  substitute  when  neither 
the  cocaine  nor  ether  can  be  secured,  and  the  emergency  demands  opera- 
tive interference.  For  fear  of  over-freezing,  the  mixture  should  be  lifted 
frequently  and  the  part  inspected. 

General  AncBsthesia. — For  any  simple  operation  which  must  of  neces- 
sity be  prolonged,  and  for  all  formidable  procedures  in  surgery,  complete 
and  general  narcosis  should  be  secured.  The  deliberate  conduct  of  an 
operation  which  is  scarcely  possible  when  a  patient  is  not  profoundly 
ansesthetized,  gives  an  assurance  of  success  not  to  be  hoped  for  under 


f  iQ.  33. — Eichardson's  atomizer,  for  the  production  of  loeal 
ansesthesia. 


ANESTHESIA.  25 

any  other  conditions  ;  and  when  to  this  is  added  the  ahnost  perfect  free- 
dom from  danger  in  properly  conducted  general  ansesthesia,  how  much 
more  should  the  profession  strive  to  educate  the  jDublic  out  of  the  un- 
founded dread  of  taking  an  aneesthetic.  It  is  this  fear  which  induces 
many  patients  to  conceal  or  silently  bear  a  malady  which,  if  operated 
upon  early,  would  prove  insignificant,  but  which,  when  left  until  pain, 
exhaustion,  or  impending  death  drives  them  to  seek  relief  at  the  hands 
of  the  surgeon,  is  too  often  formidable.  One  cause,  and  the  chief  one, 
for  this  unfortunate  condition  of  affairs,  is  the  reckless  employment  of 
these  agents,  the  lack  of  precaution  in  preparing  a  patient  for  narcosis, 
as  well  as  in  the  method  of  administration.  Of  the  various  anaesthetics 
which  have  been  introduced  for  surgical  use,  only  two  deserve  to  be 
considered,  and  in  order  of  preference  they  are  ether  and  chloroform. 

Ether  is  so  much  safer  than  chloroform  that  it  should  be  used  in  the 
large  proportion  of  cases.  The  estimated  death-rate  after  ether  is  1  in 
20,000,  for  chloroform  1  in  3,000.  While  the  value  of  statistics  may  be 
questioned,  and  admitting  that  a  certain  number  of  cases  perish  after 
ether  narcosis  from  uraemia  or  pneumonia,  the  proportion  of  fatal  cases  is 
still  so  largely  with  chloroform  that  ether  should  be  selected  as  the  safer 
agent.  All  of  the  minor  objections  to  ether  by  the  advocates  of  chloro- 
form narcosis — namely,  its  slowness  of  action,  irritation  of  the  respiratory 
tract,  nausea  and  vomiting,  inflammability,  extra  quantity  required,  etc. 
— fade  into  insignificance  when  brought  face  to  face  with  the  fact  that  the 
number  of  lives  sacrificed  by  chloroform  are  so  largely  in  excess  of  those 
after  ether  narcosis. 

In  my  opinion,  cMoroform  narcosis  is  only  justified  under  the  follow- 
ing conditions  : 

1.  In  children  under  six  years  of  age,  where  it  is  less  apt  to  cause  an 
accumulation  of  mucus  in  the  trachea  and  bronchi  than  ether.  Its 
more  rapid  and  less  irritating  action  renders  it  preferable  in  this  class  of 
patients. 

2.  In  women  in  childbirth  where  the  recumbent  posture  is  imperative. 

3.  In  an  emergency  vv^here  ether  can  not  be  obtained. 

4.  In  a  patient  who  has  previously  been  in  ether  narcosis,  in  which 
dangerous  symptoms  were  caused  by  the  ether,  or  in  which  rigidity  could 
not  be  overcome. 

5.  In  an  emergency  where  it  becomes  necessary  to  perfonn  an  opera- 
tion within  two  or  three  hours  after  the  ingestion  of  a  quantity  of  soUd 
food. 

6.  In  some  exceptional  cases  of  laryngeal  or  tracheal  stenosis. 

7.  In  patients  suffering  from  well-marked  acute  or  chronic  nephritis. 

8.  In  cases  of  extensive  bronchitis  or  jpneumonitis  with  dyspnoea. 

In  all  other  conditions  ether  should  be  given.  The  slowness  of  its  ac- 
tion is  an  objection  unfounded  in  fact,  for,  if  desired,  ether  narcosis  can  be 
effected  within  ten  minutes.  Nausea  and  vomiting  are  objections  with- 
out value  when  the  proper  precautions  are  taken  to  prevent  the  ingestion 
of  solid  food  or  milk  for  eight  hours  before  the  administration  begins. 
The  inflammability  of  ether  requires  ordinary  precaution  in  not  allowing 


26  A  TEXT-BOOK   ON   SURGERY. 

a  liglit  or  cautery  point  to  be  brought  within  five  or  six  feet  of  the  ether 
cone  or  flask.  Although  I  have  used  ether  many  times  with  artificial 
light,  I  have  never  seen  an  accident,  and  do  not  hesitate  to  recommend 
its  invariable  employment  for  night-work.  The  question  of  bulk  or 
quantity  can  only  come  up  in  remote  military  or  frontier  practice,  where 
transportation  is  difficult. 

The  Administration  of  Ether. — Complete  narcosis  may  be  obtained 
from  the  vapor  of  ether  administered  by  inhalation^  or  by  being  intro- 
duced into  the  rectum.  The  latter  method  is  rarely  practiced,  except  in 
operations  about  the  mouth. 

The  following  points  are  essential  in  the  successful  administration  of 
ether  :  Only  the  best  quality  of  ether  fortior  should  be  employed.  That 
manufactured  by  Dr.  Squibb  is  generally  preferred  in  America.  It  should 
have  a  specific  gravity  not  greater  than  0-728,  should  boil  violently  when 
in  a  test-tube  it  is  subjected  to  the  heat  of  the  hand,  and  a  bit  of  glass  is 
dropped  into  it.  The  quantity  to  be  used  will  depend  in  part  upon  the 
length  of  time  required  for  the  performance  of  the  operation,  the  con- 
struction of  the  inhaler,  and  the  idiosyncrasy  of  the  patient. 

As  ordinarily  given  with  the  Allis  inhaler,  which  allows  of  a  free  ad- 
mixture of  air  and, considerable  evaporation,  to  maintain  complete  narco- 
sis for  one  hour  will  consume  from  twelve  to  sixteen  ounces.  The  prepa- 
ration of  the  patient  is  important.  As  just  stated,  solid  or  coagulable 
food  should  be  forbidden  for  at  least  eight  hours  before  an  operation. 
The  bowels  should  be  moved  by  a  laxative  on  the  night  before  the  an- 
aesthetic is  to  be  given,  and,  if  necessary,  by  enema  on  the  morning  of 
the  same  day.  Great  care  should  always  be  given  in  the  selection  of 
proper  nourishment  for  the  patient  for  several  days  at  least  prior  to  the 
operation.  Solid  food,  with  the  exception  of  the  eight-hour  limit,  is  not 
contra-indicated  unless  the  abdominal  viscera  are  involved  in  the  opera- 
tion. A  hall-hour  before  the  anaesthesia  is  commenced,  about  two  table- 
spoonfuls  of  rye  whisky  or  brandy  in  a  teacupful  of  water  should  be 
taken  into  the  stomach.  If  the  patient  is  unusually  nervous  and  ex- 
citable, or  suffering  great  pain  or  any  marked  irritation  of  the  air-pas- 
sages, from  one  fourth  to  one  third  of  a  grain  of  morphia  should  be 
injected  hypodermically  about  twenty  minutes  before  the  inhalation.  It 
is  important  to  explain  to  the  patient  the  action  of  the  agent,  and,  above 
all,  to  impress  upon  him  the  entire  absence  of  danger  ;  that,  although  it 
will  at  first  cause  him  to  experience  a  sense  of  strangulation  or  suffoca- 
tion, yet  this  will  last  only  for  a  minute.  Finally,  artificial  teeth  or  any 
loose  substance  should  be  removed  from  the  mouth,  and  the  clothing 
loosened  about  the  neck,  chest,  and  abdomen.  Upon  a  table,  within 
reach  of  the  etherizer  or  his  assistant,  the  following  articles  should  be 
arranged  in  order  : 

1.  A  wedge-  or  screw-shaped 
piece  of  wood  for  forcing  and 
holding  the  jaws  apart  (Fig.  34). 
A  Sayre's  periosteal  elevator  is  a 

good  substitute.       2.    A   G-OOdwil-  Fig..  34. -Hard-rubber  oral: 


ANJESTHESIA.  27 

lie's  moiitli-gag  (Figs.  35  and  36)  for  keeping  the  jaws  permanently  sepa- 
rated if  the  emergency  arises.  The  Mott-Heister  gag  mil  do  as  a  sub- 
stitute (Fig.  37).     3.  A  strong  tenaculum  or  forceps,  for  drawing  out 


Fig.  35. 
Goodwillie's  mouth-gag. 


Fig.  36. 
Goodwillie's  montii-gag  in  posiSon. 


Fig.  ST. — ilott-Heister  speculum  oris. 


the  tongue.     4.   A  large-sized  curved  needle,   anned  vrith  a  good  silk 
thread,  for  transfixion  of  the  tongue  if  the  emergency  arises.     5.  Two 

or  three  curved  probangs  with 
small  sponges  tied  on,  for  mop- 
ping out  the  pharynx,  throat, 
and  mouth  (see  Fig.  43).  6. 
Several  ounces  of  whisky  or 
brandy  undiluted  :  a  hypoder- 
mic syi'inge  filled  with  this 
and  ready  for  use ;  an  ordi- 
nary syringe  for  a  whisky  or 
warm-water  enema.  7.  An  ex- 
tra can  of  ether.  8.  A  silver  trachea-tube.  9.  A  pus-basin  or  pan,  in 
case  of  vomiting.  10.  When  an  operation  which  may  involve  great  loss 
of  blood  is  undertaken,  a  ten-ounce  saline  solution  for  transfusion.  The 
formula  is  :  Common  salt,  gr.  xiry  ;  carbonate  of  soda,  gr.  v  ;  water,  3  x. 

If  necessary,   the  ether  may  be  

poiired  directly  from  the  can  into 
the  inhaler,  but  the  bottle  shown  in 
Fig.  38  will  be  found  very  conven- 
ient, and,  as  it  is  graduated,  the  quan- 
tity used  can  be  readUy  estimated. 
The  Allis  inhaler,  until  recently 
in  common  use,  "consists  of  a  wire 
framework  sufiiciently  large  to  cover 
the  lower  part  of  the  face.  The 
wires  are  parallel,  and  about  one 
eighth  of  an  inch  apart.  Between  the 
Fig.  .38.  Tvires,  fiom  side  to  side,  a  strip  of 

bandage  two  and  a  half  inches  wide 
is  passed.     Its  advantages  are  these  :  The  ether  being  very  thoroughly 
mixed  with  air,  the  patient  does  not  suffer  from  the  suffocation  usually 


28 


A  TEXT-BOOK   ON  SURGERY. 


felt  at  first  inhaling  ;  there  is  a  large  evaporating  surface.  A  very  much 
smaller  quantity  of  ether  is  used,  and  less  escapes  into  the  room  than 
with  the  usual  mode  of  giving  this  anaesthetic  ;  the  ether  can  be  dropped 
from  a  bottle  on  the  distal  end  of  the  inhaler  without  removing  it  from 
the  face  ;  the  mask  is  soft  and  pliable,  fitting  accurately  to  the  nose  and 
mouth  ;  and,  lastly,  it  is  of  very  simple  construction,  and  can  not  get  out 
of  order.  Over  this  frame  is  drawn  a  piece  of  stout  sheet  India-rubber, 
or  patent  leather,  which  has  been  stitched  together  at  the  edges,  so  as  to 
make  a  covering  for  the  frame,  projecting  over  one  end  two  inches,  to 
form  the  mask,  and  at  the  other  one  inch." 

The  great  objections  to  this  apparatus  are — (1)  the  excessive  quan- 
tity of  ether  necessary  to  produce  and  maintain  aneesthesia,  and  (2)  the 
contact  of  the  cold  vapor  with  the  air-passages. 
Neither  of  these  objections  are  present  in  the  Glover 
inhaler,  in  which  the  minimum  of  ether  is  used, 
while  the  inspired  vapor  is  warmed  before  it  reach- 
es the  trachea.  Although  as  yet  not  in  general 
use,  it  is  believed  that  this  valuable  inhaler  will  be 
more  widely  employed  as  its  merits  become  known. 

A  very  efficient  inhaler  is  repi'esented  in  Fig. 
40,  consisting  of  a  rubber  flange,  or  mouth-  and 
nose-piece,  about  three  inches  in  diameter  and 
two  in  width,  slipped  over  the  larger  end  of  an 
ordinary  lamp-chimney.  A  sponge  is  placed  in 
the  expansion  of  the  chimney,  into  which  the  ether 
is  sprinkled,  without  removing  the  apparatus,  and 
through  which  the  j)roper  quantity  of  air  can  pass 
in  and  out. 

In  an  emergency  an  inhaler  can  be  made  by 
cutting  a  piece  of  pasteboard,  twelve  inches  long 
by  seven  wide,  shaping  and  pinning  it  into  a 
cylinder,  and  lining  it  with  a  folded  towel,  or 
other  cloth.  A  notch  should  be  cut  out  to  fit  over 
the  nose,  and  the  edges  softened  by  wetting. 
Thickly  folded  newspaper  will  serve  the  same  pui'- 

pose.  A  hat-crown,  with  a  segment  removed  and  the  top  perforated, 
will  answer.  The  cloth  and  paper  cone  should  not  be  employed,  being 
objectionable  in  not  allowing  a  sufficient  admixture  of  air,  and  in  hav- 
ing to  be  lifted  from  the  face  when  additional  ether  is  required. 

In  commencing  the  administration,  which  should  be  done  in  a 
room  away  from  the  preparations  for  the  operation,  if  the  Allis  or 
any  open  inhaler  is  used  two  or  three  teaspoonfuls  of  ether  are  sprin- 
kled into  the  inhaler,  and  the  apparatus  held  about  two  inches  from  the 
lips,  the  assistant  standing  at  and  abcjve  the  patient's  head.  After  a 
minute  or  two  a  like  quantity  is  added,  and  the  rim  is  now  allowed  to 
rest  on  the  face.  The  patient  is  directed  to  breathe  freely  and  to  force 
all  the  air  out  of  the  lungs,  to  blow  through  the  inhaler,  and  to  inspire 
deeply.     No  talking  should  be  permitted  within  hearing,  except  the 


Fig.  40. 
H.  M.  Sims's  ether-inhaler. 


ANESTHESIA.  29 

words  of  direction  and  encouragement  from  the  one  ia  authority.  If  at 
the  start  an  inhaler  is  surcharged  vdih  ether,  and  placed  closely  over  the 
mouth  and  nose,  the  irritation  is  so  great  that  spasm  of  the  glottis,  ■nith 
violent  coughing,  occurs,  and  a  sense  of  strangulation,  which  frightens  the 
patient,  and  causes  an  unnecessary  struggle  and  commotion.  Indiscrimi- 
nate conversation  in  the  presence  of  a  patient  who  is  being  anjesthetized 
should  be  forbidden,  since  it  often  induces  boisterous  conduct  or  un- 
guarded expressions  from  the  half-intoxicated  subject.  In  the  course  of 
five  or  six  minutes  the  degree  of  tolerance  established  will  allow  the  ad- 
dition of  3  J  to  3  ij  of  the  antesthetic,  and  this  may  be  repeated  in  three 
or  four  minutes.  At  this  period,  about  ten  or  fifteen  minutes  after  com- 
mencing the  inhalation,  the  face  becomes  flushed  from  capillary  disten- 
tion, the  pulse  is  considerably  increased  in  power  and  frequency,  accom- 
panied by  delirium  varying  in  character  and  degree.  If  the  patient 
should  now  begin  to  struggle  and  resist  the  inhalation,  the  assistants 
should  hold  the  arms  and  legs  firmly  against  the  bed  or  table.  When 
help  is  scarce,  this  feature  should  be  anticipated,  and  a  leather  strap  or 
rope  passed  around  the  table  or  bed  and  over  the  legs.  Just  above  and 
below  the  knees,  which  should  be  tightened  at  the  proper  time.  The 
arms  should  be  held  against  the  bed  close  to  the  sides  in  fuU  exten- 
sion and  supination.  Every  few  minutes  from  3ss  to  3j  of  the  anjes- 
thetic  should  be  sprinkled  into  the  inhaler.  In  from  fifteen  to  twenty 
minutes  all  movements  of  volition  cease,  the  respirations  are  regular 
and  soft,  the  pulse  is  slightly  full  and  accelerated  ;  the  pupil,  which 
at  first  contracted,  is  now  dilated,  and  the  finger,  rubbed  along  the  eye- 
lashes or  over  the  cornea  and  conjunctiva,  produces  no  spasm  of  the 
orbicular  muscle  of  the  eye  ;  the  arms  fall  limp  and  helpless,  and  remain 
ia  any  position  in  which  they  may  be  placed.  The  patient  is  now  in  the 
second  stage,  and  it  should  be  the  aim  of  the  etherizer  to  keep  the  nar- 
cosis just  a  little  beyond  consciousness.  If  he  is  thoroughly  trained,  this 
can  almost  always  be  done ;  and  to  the  operator  the  sense  of  security 
from  the  danger  of  asphyxia,  on  the  one  hand,  and  the  annoyance  of  the 
patient"  s  becoming  conscious,  on  the  other,  is  invaluable.  In  operating 
without  a  tourniquet,  the  color  of  the  blood  which  escapes  should  be 
noticed,  for  black  blood  indicates  asphyxia,  its  sudden  cessation  heart- 
failure. 

When  in  the  course  of  narcosis  the  respiration  becomes  markedly  ir- 
regular and  infrequent,  and  the  breathing  stertorous  in  character,  the 
indications  are  those  of  too  profound  paralysis,  and  the  ether  should  be 
temporarily  disconrinued.  Lividity  of  the  face  indicates  asphyxia,  and 
demands  immediate  attention.  Asphyxia  may  occur  from  several  causes, 
and  in  any  stage  of  etherization.  In  the  first  stage,  or  stage  of  excite- 
ment, from  muscular  fixation,  the  respiratory  muscles  may  be  seized 
with  tonic  spasm,  the  chest  and  abdominal  walls  remain  immovable,  and 
the  teeth  clenched  by  contraction  of  the  muscles  of  mastication.  The 
veins  of  the  forehead,  face,  and  neck  become  enonnously  distended,  and 
the  skin  blue.  This  condition  is  not  infrequent  in  subjects  addicted  to 
chronic  alcoholism.    It  is  rare  in  other  patients  when  the  narcosis  is  gradu- 


30 


A  TEXT-BOOK   ON   SURGERY. 


ally  and  carefully  accomplished.  It  should  be  relieved  by  temporary  dis- 
continuance of  the  ether,  forcible  separation  of  the  jaws  by  means  of  the 
screw-gag,  or  other  instrument,  jpuUing  the  tongue  out  of  the  mouth  with 


Fig.  41. — (Modified  from  Esmarch.) 

a  forceps  or  tenaculum  (Fig.  41),  and  compression  of  the  thorax  by  lay- 
ing the  hands  spread  out  upon  the  lower  antero-lateral  surface  of  the 
ribs  and  pushing  inward  until  the  lungs  are  emptied,  then  allowing  the 
ribs  to  expand.  A  few  repetitions  of  this  manoeuvre  will  suffice,  and  the 
administration  of  the  ansesthesia  should  be  resumed. 

In  the  second  stag'e, 
or  that  of  complete  nar- 
cosis, respiration  is  fre- 
quently interfered  with 
by  the  tongue  gravitat- 
ing backward  upon  the 
larynx.  This  can  usual- 
ly be  corrected  by  plac- 
ing the  index-finger  be- 
hind the  angle  of  the 
jaw,  and  pressing  this 
bone  directly  forward 
(Fig.  42).  The  hyoid 
bone,  fastened  to  the 
chin  by  the  genio-hyoid 
muscles,  is  thus  pulled  forward,  and  the  tongue  is  lifted  from  the  larynx. 
If  this  does  not  succeed,  the  gag  should  be  inserted,  and  the  tongue  held 

out  by  the  tenacu- 
lum, forceps,  or  silk 
thread.  Whenever 
muciTS  accumulates 
in  the  pharynx  and 
mouth,  it  should 
Fig.  43.  be  mopped  out  by 

the  sponges  tied  to 
curved  holders  (Fig.  43).  These  should  be  carried  well  back  to  the 
larynx,  and  along  the  sides  of  the  tongue  and  biiccal  walls.  In  opera- 
tions about  the  mouth,   or  when  in  the  stage  of  muscular  spasm   the 


Fig.  42.— (Esmarch.) 


ANESTHESIA. 


31 


tongne  has  been  wounded  by  the  feetb.  coagulated  blood  may  get  into 
tbe  larynx,  and  reqnire  removal  by  tbe  sponges. 

When  vomiting  occnxs  in  ether  antesthesia,  it  is  preceded  by  a  number 
of  spasmodic  movements  of  the  muscles  of  deglutition  and  of  the  abdomi- 
nal walls.  Upon  the  supervention  of  these  symptoms  the  patient  should  be 
turned  well  over  to  one  side,  and  the  head  further  rotated  and  depressed, 
so  that  any  ejected  matter  will  gravitate  readily  out  of  the  mouth  and  into 
a  basin  held  in  readiness  for  this  emergency.  Xot  infrequently  food  in- 
gested against  the  advice  of  the  surgeon,  or,  in  some  instances,  solids  taken 
more  than  eight  hours  before  an  operation,  remain  in  the  stomach  undi- 
gested, and  are  vomited  during  the  aufesthesia.  This  accident  occurs  usu- 
ally late  in  the  narcosis,  and  is  often  caused  either  by  elevating  the  patient's 
head  too  much,  or  by  allowing  him  to  come  partially  out  of  the  narcosis. 
If  a  clot  of  blood,  or  any  occluding  substance,  be  carried  into  the  larynx  or 
trachea,  and  fatal  asphyxia  becomes  imminent,  proceed  rapidly  as  fol- 
lows :  Direct  the  windows  to  be  opened,  so  that  all  the  oxygen  possible 
may  be  admitted :  slide  the  patient  over  the  end  of  the  table  until  the 
head  hangs  down,  and  tilt  the  foot  of  the  table  up  by  placing  the  lower 
legs  upon  a  stool  or  chair.  Direct  an  assistant  to  stimulate  the  respii-a- 
tory  movements  by  bi-manual  compression  of  the  thorax  at  intervals  of 
from  five  to  ten  seconds,  while  the  operator  does  a  rapid  ti^acheotomy  and 
inserts  the  tube,  grasping  the  edges  of  the  wound  with  forceps  to  arrest 
bleeding.  If  a  tube  is  not  at  hand,  the  windj^ipe  should  be  held  open  by 
ren-actors.  which  will  also  compress  the  bleeding  vessels.    The  method  of 


Sylvester  should  now  be  carried  out :  Standing  at  the  patient's  head,  as 
he  rests  upon  the  inclined  table,  the  operator  seizes  the  arms,  at  or  near 
the  elbow,  and  presses  them  down  upon  the  thoracic  walls,  thus  forcibly 
emptying  the  longs  (Fig.  44 1,  and  immediately  thereafter  extends  them 


32 


A  TEXT-BOOK   ON   SURGERY. 


upward  parallel  witli  the  long  axis  of  tlie  body,  aiding  in  the  free  expan- 
sion of  the  chest  (Fig.  45).  This  is  repeated  from  ten  to  fifteen  times  a 
minute,  and  kept  up  by  relays  of  assistants,  if  necessary,  until  voluntary 


respiration  is  established,  or  the  heart  has  ceased  to  beat.  All  this  while 
the  mouth  should  be  kept  open,  and  the  tongue  pulled  forward  and  out 
of  the  mouth. 

Heart-failure  is  exceedingly  rare  in  the  early  stage  of  ether  narcosis. 
A  weak  heart,  as  a  rule,  is  stimulated  by  the  anaesthetic.  It  is  more  apt 
to  be  a  part  of  the  later  stage,  and  after  a  prolonged  administration  with 
loss  of  blood  or  the  added  shock  of  the  operation.  It  is  indicated  by  a 
gradual  weakening  in  the  force  and  an  increased  rapidity  of  the  pulse, 
or  by  the  rapid  supervention  of  pallor  from  sudden  stoppage  of  the 
heart.  When  the  first  condition  prevails,  pure  rye  whisky,  or  brandy, 
should  be  administered  hypodermically,  two  or  three  syringefuls  at  once 
(each  syringeful  =  3  ss.),  and  repeated  at  intervals  of  a  few  minutes  untd 
improvement  is  noticed.  A  like  result  may  be  obtained  by  injecting 
a  teacupful  of  warm  water  and  whisky  (equal  parts)  into  the  rectum. 
Elastic  bandages  should  be  thrown  around  the  extremities  in  order  to 
drive  all  the  blood  to  the  centers.  When  sudden  syncope  occurs,  place 
the  patient's  head  lower  than  the  body  by  allowing  it  to  hang  over  the 
upper  end  of  the  table,  while  the  lower  end  is  well  elevated  (Fig.  44). 
At  the  same  time  strike  sharply  upoir  the  prsecordial  region  with  the 
palm  of  the  hand,  and  shower  the  chest  and  epigastrium  with  cold  water. 

Ether  narcosis  may  be  also  secured  and  maintained  by  administering 
this  agent  by  the  rectum.  This  method  was  introduced  by  Pirogoff 
about  the  year  1847.  It  consists  in  the  introduction  of  the  vapor  of 
ether  as  follows :  A  graduated  bottle  is  fitted  with  a  perforated  cork, 
through  which  passes  a  glass  tube.  To  this  pipe  a  rubber  tube  is  at- 
tached, and  at  the  other  end  is  a  glass  tiibe  for  introduction  into  the 
anus.     The  anal  tube  being  introduced  well  into  the  rectum,  the  bottle 


ANESTHESIA.  33 

of  ether  is  placed  in  a  flat-bottomed  basin  containing  warm  water,  wMch 
causes  rapid  Taporization  of  the  angesthetic,  the  vapor  passing  into  the 
rectum,  where  it  is  absorbed  by  the  vessels.  The  quantity  can  be  regu- 
lated by  pressure  upon  the  tube  and  removal  of  the  warm  water.  An 
unpleasant  sensation  is  at  first  experienced,  and  this  is  soon  followed  by 
the  constitutional  effects  of  the  agent.  Even  when  carefully  employed, 
rectal  etherization  is  a  dangerous  procedure.  It  should  only  be  enter- 
tained in  those  rare  cases  of  extensive  dissections  about  the  mouth,  where 
the  presence  of  the  cone  would  dangerously  prolong  the  operation.  In 
one  of  my  cases,  after  having  successfully  employed  this  method  in  some 
thirty  instances,  death  resulted  fifteen  hoiu's  after  the  operation  from 
shock.  The  patient  had  been  primarily  ansesthetized  by  inhalation,  and 
the  vapor  was  not  carried  into  the  rectum  until  the  cone  was  removed 
from  the  mouth  and  nose.  Only  3  ss.  was  admitted  to  the  bowel.  The 
operation  on  the  lip  was  completed  in  twenty  minutes,  and  for  the  last 
five  minutes  the  ether  was  entirely  discontinued.  The  patient  regained 
consciousness  in  an  hour,  and,  although  complaining  of  an  uneasy  sen- 
sation in  the  abdomen,  his  condition  was  considered  good.  Ten  hours 
later  severe  ileo-colitis  developed,  followed  by  collapse  and  death.  The 
autopsy  showed  very  recent  congestion  of  the  kidneys.  The  walls  of  the 
lower  portion  of  the  ileum  and  all  the  large  intestine  were  intensely  in- 
jected.    There  was  considerable  blood  in  the  cavity  of  the  gut. 

CJiloroform. — Pure  chloroform  is  a  colorless  volatile  liquid,  with  a 
specific  gravity  of  1  '480,  not  highly  inflammable  ;  it  has  a  peculiar  odor, 
at  first  sweetish  to  the  taste,  and  afterward  burning  and  pungent.  Ap- 
plied to  the  skin,  and  prevented  from  rapid  evaporation,  it  produces  red- 
ness and  vesication.  "When  shaken  with  pure  sulphuric  acid  in  equal 
parts,  no  discoloration  ensues.  Impure  chloroform,  on  the  other  hand, 
colors  the  acid  brown. 

The  preparations  for  chloroform  narcosis  differ  in  no  essential  feat- 
ures from  those  just  given.     Since  this  anesthetic  is  more  powerful,  a 


Fig.  48. — (Esmarch.) 

much  smaller  quantity  is  used.     A  simple  napkin  folded  into  a  square  of 
five  or  six  inches  wiU  suffice  as  an  inhaler.     The  apparatus  of  Esmarch 
3 


34  A  TEXT-BOOK   ON  SURGERY. 

(Fig.  46)  is,  however,  preferable.  It  is  composed  of  a  wire  frame  shaped 
to  fit  over  the  nose  and  mouth,  the  center  wire  extending  up  an  inch  or 
more,  and  bent  into  a  hook.  Over  this  a  piece  of  canton-flannel  or  soft 
cloth  is  stretched  so  tightly  that  the  threads  are  parted  sufficiently  to 
allow  the  free  passage  of  air  through  the  covering.  To  the  upper  end  or 
hook  a  tape  is  attached,  and  tied  around  the  head  in  such  a  position  that 
the  inhaler  falls  over  the  mouth  and  nose.  The  administration  is  begun 
by  pouring  twelve  or  fifteen  drops  of  the  anaesthetic  upon  the  inhaler  or 
napkin.  A  free  admixture  of  air  is  neccessary.  The  napkin  should  not 
be  held  in  contact  with  the  lips  or  nose,  for  fear  of  shutting  ofl:  the  proper 
quantity  of  air.  It  is  a  wise  precaution  to  cover  the  skin  about  the  mouth 
and  nose  with  vaseline  to  prevent  the  irritating  effect  of  the  chloroform. 
In  two  or  three  minutes  the  same  quantity  is  renewed,  and  so  on  until 
sensibility  and  consciousness  are  lost.  Chloroform  narcosis  may  also  be 
divided  into  three  stages. 

The  first  is  the  stage  of  excitation.  In  this  the  pulse  is  usually  in- 
creased in  force  and  frequency,  the  face  is  flushed,  the  pupil  normal  or 
contracted  ;  delirium  is  present,  and  a  condition  of  muscular  rigidity  en- 
sues, varying  in  degree  in  different  subjects.  It  is  almost  always  well 
marked  in  patients  of  the  alcohol  habit.  The  second  stage  is  that  in 
which  sensibility  and  consciousness  are  lost,  yet  in  which  the  functions 
of  the  heart  and  respiratory  organs  are  performed  in  an  almost  natural 
manner.  The  pupil  is  now  dilated  and  arterial  tension  diminished.  In 
the  third  stage,  that  of  profound  paralysis,  the  breathing  becomes  shal- 
low and  stertorous,  the  heart-beats  rapid  and  weak,  and  the  arterial  ten- 
sion is  markedly  diminished. 

The  second  is  the  operatme  stage.  The  tMrd  should  be  avoided. 
Death  during  the  inhalation  of  chloroform  occurs  from  both  heart  and 
respiratory  failure,  and  may  take  place  in  any  stage  of  the  narcosis.  It 
is  the  heart,  however,  which  fails  in  the  vast  majority  of  fatal  cases,  and 
this  organ  not  infrequently  suddenly  and  without  warning  ceases  to  beat. 
On  the  other  hand,  ether,  when  given  in  lethal  doses,  paralyzes  the  res- 
piratory muscles,  of  which  there  are  almost  always  premonitory  symp- 
toms that  will  not  escape  the  acute  observer  and  cautious  surgeon. 
When  natural  respiration  fails,  artificial  means  may  be  readily  employed 
and  life  saved  by  keeping  up  a  sufficient  quantity  of  air  until  the  effects 
of  the  ether  passes  away.  In  heart-failure  from  chloroform  there  is  little 
hope  of  restoration  of  function. 


CHAPTER  IV. 


STIEGICAL   OPEKATIOiNS. 


Instruments. — Much,  of  success  in  practice  depends  upon  tlie  pos- 
session of  a  variety  of  instruments  which,  should  be  of  the  very 
best  material,  made  after  well-approved  patterns,  and  as  simple 
in  construction  as  possible.     The  best  instruments  are  now  made 
Avith  good-sized  handles,  not  large  enough  to  be  cumbersome, 
but  sufficiently  large  to  be  grasped  firmly  in  the  hand.     For  all 
knives,  retractors,  gouges,  etc.,  the  handles  are  made  of  vulcan- 
ized rubber,  which  is  molten  on  to  the  steel,  and  does  not 
therefore  require  to  be  riveted.     This  material  is  suscep- 
tible of  a  high  polish,  and  is  easily  kept  clean.     All  sur- 
faces should  be  perfectly  smooth  and  plain,  even  to  the 
extent  of  omitting  the  stamp  of  the  manufacturer.     For 
amputations  and  ordinary  operations  on  the  soft  parts 
and  bones,  the  following  articles  are  required : 

For  making  flaps  by  ti'ansfixion,  two  amputating- 
Jcnives.  The  largest  of  these  (Fig.  47)  *  measures  17  inch- 
es over  all,  or  12  inches  for  the  cutting  blade,  the  width 
of  which  is  five  eighths  of  an  inch.  The  rubber  handle 
has  a  ciiTumferenee  of  two  and  a  half  inches. 

Fig.  48  represents  a  smaller  knife  of  a  similar  pat- 
tern, the  blade  of  which  is  only  eight  inches  long  by  half 
an  inch  wide. 

The  scalpels  are  eight  in  number,  the  blades  ranging 
from  two  and  a  half  to  three  fourths  of  an  inch  in  length. 


The  handles  are  large  enough  to  be  firmly  held,  and  the 
end  of  each  is  shaped  into  a  dry  dissector  (Figs.  49  and  50). 
Fig.  48.  A  probe-pointed  and  a  sharp,  curved  histoury  (Figs. 

*  These  cuts  are  made  from  the  instruments  in  my  general  operating-case. 


36 


A  TEXT-BOOK   ON   SURGEKY. 


51  and  52),  with  blades  of  three  and  a  half  inches  cutting  edge,  are  in- 
valuable instruments. 

Two  lUTiotomy-Jcnives 
(Figs.  53  and  54),  one 
probe-pointed,  the  other 
sharp,  with  blades  of  four 
inches  cutting  surface. 
The  probe-pointed  knife 
is  for  the  lateral,  the  oth- 
er for  the  median  opera- 
tion. 

For  the  cutting 
part  of  the  opera- 
tion for  cleft  pal- 
ate, three  blades  are  need- 
ed.    A  double-edged  bis- 
toury for  commencing  the 
incision  in  trimming  the 

edge  of  the  soft  palate  (Fig.  55),  the  cutting  edge  of  which  is  five  eighths 
of  an  inch  long ;  a  curved  probe-pointed  bistoury  of  one  and  a  quarter 

inch  blade  (Fig.  56), 


Fig.  53. — Little's  lithotomy-kiiifc. 


Fig.  54. — Blizzard's  prote-pointed  lithotomy-knife. 


ill  WW  II    1 1 II I II 


^ 


---^-^-^--TjiiiffiiiiMrMiiiiiiiiiiiniaii 


and  a  short  blade 
turned  at  almost  a 
right  angle  to  the 
shaft  {'■'■  gum-lan- 
cef^)  for  dividing 
the  mucous  and  pe- 
riosteal tissues  on 
the  hard  palate 
(Fig.  67). 
For  the  subcutaneous  section  of  tendons  and  fascia,  a  probe-pointed 
tenotome,  the  shaft  and  blade  together  measuring  two  inches,  the  cutting 


edge  of  the  blade  three  fourths  of  an  inch  long  (Fig.  58),  and  a  small 
fascia-Jcnife  (Fig.  59)  for  multiple  division  of  the  palmar  or  plantar  fascia. 
Retractors,  or  instruments  for  holding  the  edges  and  walls  of  wounds 
steady  and  out  of  the  way, 
should  have  long  shafts 
and  handles,  so  that  the 
hands    of    the   assistants 
may   not    shut    out    the 
light,  or  otherwise  inter- 
fere   with    the    operator. 


SURGICAL  OPERATIONS. 


37 


They  should  also  have  sharp  or  hooked  claws  for  catching  firm  hold  in 
tissues  away  from  important  vessels,  organs,  or  nerves  (Fig.  60),  while 

others  should 
be  dull,  and 
curved,  or 
bent  on  the 
flat  (Fig.  61). 
A  tenacu- 
lum (Fig.  62) 
should  be  in 
every  case. 
The  aneurism-needle  (Fig.  63)  will  often  serve  a  useful  purpose  as  a  re- 
tractor. The  essential  features  of  this  important  instrument  are  a  capa- 
cious eye,  a  simple 
curve  in  one  direc- 
tion, and  a  dull 
point  which  can  not 
be  forced  into  the 
wall  of  a  vessel. 

The  instruments 
for  operations  upon 
the  bones  are  prob- 
ably the  most  important  in  the  surgeon's  outfit.     The  list  should  include 
saws,  chisels,  gouges,  elevators,  drills,  forceps,  an  exsector,  and  a  mallet 
and  trephine. 


Fig.  64. — Bow-saw,  with  two  l.lades. 


Fig.  64  represents  the  most  convenient  saw  for  amputations  and  ex- 
sections  of  the  knee-  and  elbow-joints.  There  are  two  blades,  either  of 
which  may  be  adjusted  at  pleasure. 


Fig.  65. — The  author's  adjustable  key-hole  saws 


For  operations  upon  the  bones  of  the  face,  as  in  exsection  of  the 
superior  maxilla,  or  the  osteoplastic  operation  for  removal  of  the  spheno- 


38 


A  TEXT-BOOK   ON   SURGERY. 


palatine  ganglion,  etc.,  the  adjustable  key -hole  saws  (Fig.  65)  are  needed. 
There  are  three  blades,  which  can  be  attached  by  a  screw-catch  to  a 
single  handle. 

Chisels  are  of  two 
kinds — those  to  be 
driven  by  a  mal- 
let or  hammer,  and 

hand-chisels,  for  cutting  or  gouging.  They  are  straight-edged  and 
curved.     Fig.  66  is  a  half -size  picture  of  Macewen's  osteotome.     Two  of 

these  will  be  requii-ed,  and 
should  measure,  respective- 
ly, one  half  and  three  eighths 
G.TJETMANN Scca       JiviL       '^^  ^'^  ^^'^''^  ^^  "tt"idth  at  the 
cutting   edge.      A   conven- 
ient Tiammer  for  driving  the 
chisel  through  is  seen 
in  Fig.  67. 

Yolkmann's    sTiarp 

spoons  or  scoops  (Fig. 

Fi"^-  68.  68)    are  invaluable  in 

certain  operations. 

The  scalloped  gouges  (Fig.  69)  are  to  be  used  with  the  hand  without 

the  mallet. 

Sayre's  p>eriosteal  ele- 
vator (Fig.  70)  meets  al- 
most every  requirement 
for  lifting  the  periosteum, 
and  is,  besides,  an  excel- 
lent bone-elevator.  For 
lifting  the  periosteum  from 
the  palate-bones,  the  three 
instruments  of  Goodwil- 
lie  are  very  useful  (Fig. 
71). 

Bone-drills  are  not  as 
often  used  now  as  in  for- 
mer years,  yet  they  may 
be    needed    occasionally. 

One  or  two  are  burred  with  as  many  plain-edged  cutting  diills  (Fig.  72). 

For  purposes  of  econ- 
omy in  space,  a  single 
adjustable  handle  is 
arranged  for  all  the 
didlls. 

Bone  -forceps 
should  be  constructed 
for  cutting,  holding, 
and  exti'actins  uses. 


SURGICAL    OPERATIOXS. 


39 


Those  that  cut  are  of  the  two  shapes  sho-mi  in  the  accomiDanTing  illusti-a- 
tions  (Figs.  73  and  74). 


Tig 


Hamilton's  sequestrum-forceps,  an 
excellent  instrument,  is  shown  in  Fig. 
75. 

X  rongeur^  or  forcej)S-gouge.  is  es- 
pecially useful  in  operations  upon  the 

cranial  bones,  where  any  projecting  angles  may  be  gnawed  off.  the  em- 
ployment of  a  mallet  and  chisel  being  always  contraindicated  (Fig.  76). 

Fig.  77  represents  a 
strong  sequ€sfruin-for- 
eeps,  and  Fig.  78  the 
lion -jawed  forceps,  a 
necessary  instrumentfor 

Fig.  75. — Hamilton's  sequestrum-forceps.  tJXatlOn. 


TIEUANN  &  CO 


For  exsections  of  the  long  bones,  excepting  the  expansions  of  the 
femur  and  tibia,  at  the  knee-joint,  and  in  tarsotomy  and  other  radical 


operations,  which  will  be  given  in  the  text,  the  exseetor  (,Fig.  79;  is  one 
of  the  most  useful  instruments  known  to  this  date.     I  have  employed  it 


now  in  about  all  the  exsections  possible,  and  it  has  always  met  every 
requirement.     Upon  the  very  hardest  bones,  such  as  the  inferior  maxilla, 


40 


A  TEXT-BOOK   ON   SURGERY. 


it  is  essential  to  have  the  saw  well  sharpened.     The  original  instrument 

was  modeled  by  Mr.  Gowan,  of  London,  but  it  was  so  complicated  in  its 

mechanism  that  I  have  had  it  extensively  modified  and  at  the  same  time 

simplified.     As  now  manufactured,  it  consists  of  a  four-jointed  forceps, 

the  Jaws  of  which  are  at  a  right  angle  to  the 

! ;  ;  handles.    At  li  is  seen  a  shield  which  not  only  ro- 

'•}"■"  tates,  but  is  reversible  and  readily  shifted  to  one 

;;  j  or  the  other  side.     The  saw,  ^,  is  chisel-shaped. 

\  I  The  outer  edge  of  the  last  tooth  is  dulled  to 

J^  l^-i  prevent  wounding  the  soft  parts  surrounding  the 


bone.  The  handles  are  held  closed  by  a  clamp,  /.  After  the  periosteum 
has  been  lifted,  separate  the  jaws  to  the  required  extent,  and  slip  them 
on  between  the  periosteum  and  bone  until  the  latter  is  well  in  the  grasp 
of  the  instrument.  Close  the  handles  sufficiently  tight  to  hold  the  bone 
steady  without  crashing  it,  and  lock  them  in  the  required  position  with 
the  clamp.  The  saw  is  now  slid  into  the  flanges  upon  the  shield  until  it 
rests  upon  the  bone,  when,  by  a  short  lateral  sawing  motion,  it  may  be 
made  to  travel  rapidly  through  the  bone.  A  very  little  care  will  prevent 
the  adjacent  soft  parts  from  being  injured. 

The  best  trephine  for  all  purj^oses  is  that  of  Gait  (Fig.  80),  the  burr  of 
which  is  conical.  A  convenient  size  is  one  which  measures  five  eighths 
of  an  inch  in  diameter  at  the  cutting  teeth,  and  gradually  enlarges  to 


seven  eighths  of  an  inch  in  diameter  at  the  base  where  the  spiral  teeth 
terminate.  The  mechanism  of  this  instrument  is  such  that,  as  soon  as 
the  resistance  in  front  ceases,  the  side-teeth  take  hold  so  greedily  that 
the  further  rotation  of  the  trephine  is  diflacult.  The  resistance  is,  how- 
ever, not  so  great  that  it  may  not  be  overcome,  and  the  teeth  driven  on 
into  the  dura  mater  aud  brain,  yet  it  is  sufficient  to  warn  the  operator 
that  the  section  is  complete. 

^  For  the  prevention  or  arrest  of  haemorrhage  there  are  needed  a  tour- 
niquet, elastic  ligatures,  various  forms  of  forceps,  and  a  wire  ecraseur  or 
clamp. 


SURGICAL   OPERATIONS. 


41 


Esmarch's  elastic  bandage  (Fig.  81)  has  superseded  all  other  tourni- 
quets for  operations  upon  the  extremities.     The  rubber  clamp  usually 

sold  with  the  bandage  is  useless.  Each 
operating-case  should  be  provided  with 
two  bandages  of  strong  elastic  material 
(I  prefer  plain  white  rubber)  about  two 
inches  wide,  and  each  bandage  about 
four  yards  long.  For  simple  constric- 
tion of  a  limb  a  good-sized  rubber  tube 
can  not  be  surpassed. 

The  elastic  ligature  is  a  solid  cord  of 
plain  rubber  about  two  feet  long,  and  of 
diiferent  sizes,  varying  from  one  twelfth 
iiG.  81.  to  one  tifth  of  an  inch  in  diameter. 

Hcemostatic  forceps  should  be  of 
various  shapes.  The  four  varieties  which  I  employ  are  illustrated  in 
Fig.  82.  A  general  operating-case  should  contain  a  total  of  at  least  six- 
teen forceps,  and  in  the  proportion  of  two  fenestrated  mouse-tooth,  six 
broad,  solid-jawed,  four 
slender-jawed,  and  four 
scissor  -  clamps  ;  the 
first  three  have  sliding 
catches,  while  the  clamp 
has  a  spring-catch  near 
the  end  of  the  handles. 
The  mouse-tooth  fenes- 
trated forceps  is  for  ac- 
curate adaptation  to  su- 
perficial vessels  of  small 
size,  while  the  broad- 
jawed  instrument  is  for 
grasping  either  large 
vessels  or  masses  of 
bleeding  tissue.  The 
points  should  be  club- 
shaped  and  perfectly 
smooth,  so  that  when 
the  ligature  is  tightened 
upon  the  instrument  it 
vdll   slide   over  its  tip 

and  on  to  the  vessel.  These  pieces  are  five  inches  long  and  three  eighths 
of  an  inch  across  the  widest  portions  of  the  jaws.  The  sharp-pointed 
forceps  are  useful  in  picking  ujd  a  vessel  which  has  retracted  or  is  deeply 
situated  in  a  wound.  The  scissor- clamps  may  be  used  for  applying  the 
double  ligatures  in  a  dry  dissection,  or  for  temporary  hsemostasis  of 
smaller  bleeding  points  which  need  to  be  compressed  for  a  few  minutes, 
and  then  remain  permanently  occluded. 

In  operations  in  the  various  cavities,  and  in  deep  external  wounds,  as 


42 


A  TEXT-BOOK   ON   SURGERY. 


well  as  for  various  purposes,  to  be  given  in  detail  hereafter,  sponge- 
holders,  similar  to  those  represented  in  Fig.  83,  can  not  be  dispensed 
with.  They  should  be  solid  in  construction,  10  inches  long,  some 
straight  and  others  curved. 


Every  operating-case  should  also  contain  the  following  instruments : 
At  least  five  pairs  of  scissors — one  pair  8  inches  long,  curved  on  the' 
flat,  with  both  points 

o 


dull  (Fig.  84) ;  a  sim- 
ilar instrument  with 
sharp  points  ;  another 
6  inches  long,  curved 
on  the  flat,  v,'ith  both 
points  sharp,  for  re- 
moving sutures,  etc. 
(Fig.  85) ;  one  straight 
sharp-pointed  Sims's 
scissors,  8  inches  long 
(Fig.  86) ;  and  a  blunt- 
pointed,  plain  dress- 
ing-scissors, 6  inches  long  (Fig.  87).  These  should  all  be  strong,  with 
the  exception  of  the  small  sharp-pointed  pair,  with  the  curve  on 
the  flat. 


Fio.  85. — Curved  iris- scissors  ;  also  used  for 
romoving  fine  sutures. 


Fig.  87. — Dressing-scissors. 


One  sliding-catch  needle-holder,  the  shape  and  mechanism  of  which 
are  fully  explained  in  Fig.  88.  The  point  should  have  a  plain  and 
curved  surface,  for  straight  and  curved  needles  (Figs.  89  to  93). 

Two  pairs  of  plain  anatomical  forceps  (Fig.  94),  fully  7  inches  long,  so 


SURGICAL   OPERATIONS. 


43 


Fig.  88. — Wveth's  needle-holder. 


Fig.  89. — Assorted  curved  and  half  curved 
fine  needles. 


6,  TIEMANN  &  CO 
Fig.  92. — Wire  suture-needles. 


Fig.  91. — Straight  and  cui'ved  needles. 


Fig.  93. — Full-curved  suture-needles. 


that  the  hand  may  be  kept  at  a  sufficient  distance  away  from  the  wound ; 

and  one  mouse-tootli^  8  inches  long,  with  a  sliding  catch. 

One  Nelaton's 
porcelain-t  ipp  e  d 
hullet  -  2>robe  (Fig. 
95),  one  long  sil'ver 
probe,  with  an  eye 
at  one  end  (Fig.  96), 
and  one  or  two  gal- 
vanized  copper 
probes,  from  10  to 
19  inches  long  and 
from  iV  to  i  inch  in 

Fia.  95. — ^Nelatou's  bullet-probe,  with  porcelain  head.  Cllameter  (-tig.  »<;• 


44 


A  TEXT-BOOK  ON   SURGERY. 


Two  good- sized  silver  grooved  directors^  six  to  seven  inches  long  and 
from  one  eiglitli  to  three  sixteenths  of  an  inch  in  width  (Fig.  98). 


Fig.  9«.— i'luhrcr's  light  tk-xiMu  bulb-tipped  pro 


Fig.  97. — IjOiig  silver  probe. 


Fig.  98.— Grooved  director. 


Other  instruments  will  be  given  in  the  text,  with  the  operations  for 
which  they  are  especially  designed. 

Place  of  Operation.— In  the  performance  of  a  surgical  operation,  a 
clean  room,  good  light,  and  a  free  supply  of  fresh  air  are  of  first  impor- 
tance. The  supply  of  light,  in  order  to  be  most  effective,  should  fall  upon 
the  operating-table  from  points  above  the  level  of  the  patient.  In  the 
open  air  and  in  daylight,  when  protected  from  the  direct  rays  of  the  sun, 
the  best  conditions  for  light  and  air  prevail.  Under  shelter,  a  sky -light, 
or  a  tall,  wide  window,"  are  pi-eferable.  At  night,  gas,  lamps,  candles,  or 
torches,  must  often  do  the  best  service  possible  in  an  emergency.  The 
Edison  electric  light,  in  which  the  incandescent  carbon  is  held  within  an 
air-tight  globe,  furnishes  the  safest  and  most  effective  artificial  light. 

It  is  always  desirable  to  control  the  temperature  of  an  operating- 
room,  and  to  keep  it  at  a  figure  above  that  necessary,  or  even  comfort- 
able, to  the  ojDerator  and  attendants.  The  patient's  body  is  almost 
always  in  part  exposed,  and,  in  addition,  is  apt  to  be  deprived  of  the 
normal  body-heat  by  haemorrhage  and  shock.  Moreover,  in  the  event  of 
asphyxia,  the  rapid  introduction  of  fresh  air  from  the  open  windows 
may  be  imperative,  and  the  temperature  lowered  to  a  dangerous  degree, 
if  the  room  is  not  provided  with  the  proper  means  of  heating. 

The  room  in  which  an  operation  is  to  be  performed  should  be  large 
enough  to  hold  all  the  necessary  apparatus  and 
furniture,  and  to  allow  the  free  and  rapid  move- 
ments of  the  attendants  in  the  execution  of 
orders.  The  floor  should  be  of  wood,  tiles,  as- 
phalt, or  marble,  uncarpeted  and  clean ;  the 
walls  and  ceilings  equally  clean,  and  free  from 
unnecessary  drapery.  In  a  dusty  country  the 
steam-spray  (1  to  20  carbolic  acid)  should  be 
used  before  and  during  an  operation  (see  Fig. 
4),  and  likewise  in  all  conditions  of  exposure  to 
infection,  such  as  a  room  in  or  near  which  a 
contagious  disease  has  once  appeared,  etc. 

The  furniture  required  consists  of  an  operat- 
ing-table, at  least  two  side- tables,  or  cabinets,  for 
Fig.  99.— Adjustable  stool.        holding  trays  of  instruments,  sponges,  dressings, 


SURGICAL   OPERATIONS. 


45 


solutions,  irrigators,  etc.  An  adjustable  stool  (Fig.  99)  for  the  surgeon 
should  be  among  the  accessories.  An  operating-table  should  be  made  of 
strong  material,  solidly  put  together,  6i  feet  long,  3-i  inches  high,  and  22 
in  width,  padded  %vith  cotton,  wool,  hair,  or  felt,  to  the  thickness  of  about 
one  inch,  and  covered  with  some  good  water-proof  material.  In  mod- 
ern ]3ractice,  with  the  free  use  of  irrigating  solutions,  it  is  necessary  to 
arrange  the  operating-table  so  that  all  fluids  will  be  conducted  into  a 
vessel  without  wetting  the  patient  beyond  the  field  of  operation.     Dr. 


Fig.  100. — Ladinski's  operating-taWe. 


Ladiaski's  table  (Fig.  100)  fully  answers  these  requirements.  The  surface 
of  this  excellent  table  is  divided  into  a  central  padded  ridge  ten  inches 
in  width,  and  two  lateral  portions,  each  about  seven  inches  wide,  which 
slope  sharply  toward  the  two  deep  grooves  or  troughs,  extending  the 
entire  length  of  the  to]3.  These  grooves  should  be  wide  enough  to  per- 
mit of  thorough  cleansing.  All  the  fluids  used  in  irrigation  flow  fi'om 
the  field  of  operation  into  the  troughs,  and  run  oflE  on  the  lower  end 
through  the  tin  gutter  into  a  vessel  beneath.  In  an  emergency,  a  con- 
venient covering  for  a  table  may  be  made  as  follows :  Ai'ound  two 
poles  of  a  length  equal  to  that  of  the  table,  and  an  inch  or  two  in  diame- 
ter, roU  cotton-batting,  or  pieces  of  blanket,  until  the  whole  is  about 
three  inches  iu  diameter.  Two  ordinary  blankets  rolled  tightly  will 
suffice.  At  intervals  of  a  foot  connect  these  side-bars  by  wisps  of  band- 
age-cloth long  enough  to  hold  the  bars  parallel  with  each  other,  and 
with  the  long  edges  of  the  table  on  which  they  rest.     This  skeleton,  or 


46 


A  TEXT-BOOK   ON  SURGERY. 


frame,  is  lashed  securely  to  tlie  table,  and  an  oil-cloth  laid  over  it  (Fig. 
101).  If  the  head  of  the  table  is  raised  four  or  five  inches  on  blocks,  the 
patient  rests  in  a  kind  of  trongh,  along  which  the  solutions  are  carried 
away  fi'om  the  parts  of  the  body  not  to  be  irrigated. 

When  such  a  table  is  not  convenient,  one  may  be  extemporized  from 
an  ordinary  dining-  or  side- table,  or  two  of  these  placed  endwise.  All 
household  furniture  so  used  should  be  thoroughly  washed  and  scrubbed, 
and  then  covered  with  clean  sheets.    The  side-tables  for  dressings  should 


be  also  cleansed  and  covered  with  sheeting.  It  is  always  important  to 
have  plenty  of  room,  so  that  the  various  articles  and  instruments  may  be 
arranged  in  the  order  in  which  they  will  be  needed.  A  hard-wood  cabinet 
(Fig.  102),  about  3  by  2  feet  (surface  measurement),  will  serve  an  excellent 
purpose  for  holding  trays  of  instruments,  ligatures,  etc.,  while  the  draw- 
ers supplied  with  materials  in  reserve  may  prove  convenient  at  any  stage 
of  the  operation. 

The  trays  for  holding  instruments  submerged  in  carbolic-acid  solution 
should  be  made  of  porcelain  or  tin,  not  more  than  two  inches  deep,  and 
of  various  lengths,  to  meet  the  requirements  of  the  largest  instruments. 


SURGICAL   OPERATIONS. 


47 


48 


A  TEXT-BOOK   ON   SURGERY. 


For  purposes  of  convenience,  tlie  tin  tray  may  be  divided  into  compart- 
ments for  the  several  outfits— one  for  tlie  lisemostatic  apparatus,  anotlier 
for  knives,  a  third  for  bone  instruments,  and  a  fourth  for  odds  and  ends. 
Every  basin  so  used, 
and  each  compart- 
ment, should  have  a 
tamed  corner  like 
the  mouth  of  a  pitch- 
er for  readily  emp- 
tying the  solution 
when  necessary 
(Figs.  103,  104,  105). 

Fig.  !('■'■.  — 11.  M.  ^^ims's  instriiment-trav. 


Pus-basins  (Fig.  106)  are  veiy 
useful  for  receiving  vomited  matter 
or  for  catching  pus,  irrigating  solu- 
tions, etc.  Such  vessels  should  be 
made  of  tin  or  brass,  and  not  of 
hard  rubber,  for  these  are  easily  ^m.  los. 

broken,  and  can  not  be  repaired. 

Larger  vessels,  such  as  bottles  or  pitchers,  of  glass  or  porcelain,  or 
clean  wood,  should  be  filled  with  the  various  solutions  to  be  used,  and 
kept  at  a  temi^erature  between  100°  and  110°  F.  As  the  operation  is  about 
to  begin,  the  irrigator  should  be  filled  with  sublimate  (1  to  3,000),  and 
the  sponges  placed  in  a  warm  solution  of  the  same  strength  from  which 
they  are  taken  as  required. 

The  dressings  to  be  applied  should  be  cut  and  laid  in  order,  so  that  no 
delay  may  be  experienced.  Ligatures  and  sutures  should  also  be  cut 
beforehand  and  placed  in  appropriate  receptacles,  the  catgut  in  oil  of 
juniper,  the  silk  or  wire  in  1  to  20  carbolic  acid. 

The  i^reparation  of  a  patient  has  a  moral  as  well  as  a  physical  aspect. 
The  siu'geon  and  attendants  should  labor  Judiciously  to  dispel  anxiety 
by  assuring  the  patient  of  the  safety  of  ether,  and  the  freedom  from  pain 
which  follows  even  the  most  extensive  incisions.  The  question  as  to 
whether  an  unfavorable  prognosis  should  be  made  known  to  the  patient 
must  be  determined  by  the  circumstances  which  prevail.  The  profes- 
sional obligation  is  discharged  when  the  nearest  relations  and  friends  are 
so  informed.  If  the  temperament  of  the  individual  is  such  that  great 
depression  would  probably  follow  the  knowledge  of  impending  disaster, 
and  thus  add  to  the  dangers  of  the  case,  it  will  be  wise  to  advise  the 
friends  to  withhold  the  information.     The  surroundings  of  all  such  pa- 


SURGICAL   OPERATIONS. 


49 


tients  should  be  as  briglit  and  cheerful  as  possible.  Gfood  light,  food, 
and  air,  and  kind  attentions  from  friendly  hands,  add  much  to  secure  a 
successful  issue. 

The  physical  preparation  may  be  general  or  special,  and  the  time  to 
be  devoted  to  it  must  depend  in  great  measiire  uioon  the  nature  of  the 
disease  or  injury,  and  the  condition  of  the  individual.  If  a  condition  of 
marked  sepsis  prevails,  delay  is  dangerous,  for  aU  efforts  at  nutrition 
will  be  more  than  offset  by  continued  absorj)tion  of  the  poison.  The 
same  rule  will  apply  in  haemorrhage  not  controllable  by  compression. 
In  most  instances,  however,  much  good  can  be  achieved  by  devoting 
several  days,  or  even  weeks,  to  increasing  the  nutrition  of  the  tissues. 
Properly  selected  food  and  tonics,  the  regulation  of  the  bowels,  sound 

and  refreshing  sleep,  and  freedom 
from  pain,  are  all  essential.  When 
the  abdominal  organs  are  to  be  ex- 
posed, especially  in  operations  upon 
the  alimentary  canal  and  the  re- 
moval of  large  tumors,  solid  food 
should  be  withheld  for  at  least  five 
days  prior  to  the  operation,  and 
concentrated  liquid  nourishment, 
such  as  beef-juice  and  milk,  taken 
in  its  stead.  In  addition  to  this,  a 
laxative  should  be  administered  on 
the  day  before,  and  an  enema  on 
the  morning  of,  the  operation.  Fi- 
nally, just  before  the  ansesthesia, 
the  parts  about  the  held  of  opera- 
tion should  be  shaved  and  cleansed, 
provided  that  this  is  not  painful  to 
the  patient.  The  other  features  of 
preparation  have  been  given  in  the 
chapter  on  Angesthesia. 

The  preparation  of  the  surgeon 
and  attendants  is  also  of  great  im- 
portance, and  is  compirehended  in 
the  greatest  j^ossible  personal  clean- 
liness.    No  one  should  be  admit- 
ted to  the  presence  of  the  patient 
who  has  been  in  a  room  with  a  con- 
tagious disease  within  twenty-four 
hours,  or  who  has  not  made  a  per- 
fect change  of  clothing,  and  thor- 
oughly washed  all  over.     The  nails 
should    be    closely    trimmed    and 
cleansed,  the  hands  and  arms  washed  with  soap  and  water  and  brush, 
and  afterward  in  1  to  3,000  sublimate.      The  operator  should  wear  a 
water-proof  gown,  long  enough  to  reach  to  the  feet.     The  arms  should 
4 


Fig.  107. — Surgeon's  water-proof  operating-gown. 


50 


A  TEXT-BOOK   ON   SURGERY. 


be  covered  with  sleeves  of  the  same  material,  pinned  at  the  shoulders  and 
extending  half-way  between  the  elbow  and  wrist  (Fig.  107).  A  linen  coat 
will  also  sufBce,  but  will  not  always  protect  the  person  from  the  irrigat- 
ing solutions.     The  attendants  should  all  be  clad  in  clean  gowns. 

Everything  being  in  readiness,  and  the  patient  ansesthetized,  brought 
in,  and  placed  upon  the  table,  the  following  arrangement  and  assignment 
of  duties  should  be  made :  The  table  must  be  so  turned  that  the  best 
light  falls  upon  the  field  of  operation.  All  parts  of  the  body  out  of  this 
field  should  be  well  wrapped  up  and  protected  from  getting  wet  by 
blankets,  and  an  oil-cloth  over  all.  The  parts  within  range  of  the  oper- 
ation, haviag  previously  been  shaved  and  scrubbed  with  soap  and  water, 
are  now  washed  with  ether,  and  then  with  1  to  3,000  sublimate.  If  the 
tourniquet  is  to  be  applied,  say,  to  an  extremity,  towels  dipped  in  warm 
sublimate,  1  to  3,000,  are  wrapped  about  the  part,  and  the  elastic  band- 
age applied  over  these.  When  the  bandage  is  removed  up  to  the  point 
where  the  limb  is  to  remain  constricted,  this  and  all  parts  near  the 
wound  should  be  covered  over  with  warm  sublimate  towels. 

The  assistants  should  be  as  follows :  A  trained  etherizer,  and  a  first 
assistant  to  sponge  and  immediately  help  the  operator,  who  stands  usu- 
ally just  opposite  him.  A  second  assistant,  to  stand  conveniently  to  the 
instruments  and  the  'operator,  whose  duty  it  is  to  hand  each  instrument 
or  article  as  called  for  with  promptness,  and  as  promptly  to  remove  those 
which  have  been  laid  aside.  A  third  assistant  attends  to  the  irrigation, 
regulating  the  supply  at  the  indication  of  the  chief.  One  supernumerary, 
for  holding  retractors,  or  performing  any  duty  which  may  be  required. 
A  nurse  to  rinse  the  sponges  and  hand  them  to  the  first  assistant.  A 
second  nurse  to  assist  the  etherizer.  A  supernumerary  nurse  for  general 
usefulness. 

When  the  knife  (or  other 
instrument)  is  lifted  from  the 
solution,  the  assistant,  before 
handing  it  to  the  operator, 
shakes  from  it  the  few  drops 
of  fluid  which  adhere,  for  the 
acid  irritates  the  skin  and 
obscures  to  some  extent  the 
incision.  Different  methods 
of  holding  the  scalpel  in 
making  an  incision  are  rep- 
resented in  Figs.  108  and  109. 
Holding  the  handle  between 
the  thumb  and  middle  finger, 
while  the  tip  of  the  index- 
finger  rests  upon  the  back  of 

the  blade,  will  be  found  most  iiseful  in  cutting  through  the  skin,  and  in 
rapid  work  in  parts  of  the  body  away  from  the  more  important  vessels 
and  nerves,  such  as  the  removal  of  the  breast.  The  advantages  of  this 
position  are,  that  more  of  the  cutting-edge  is  utilized,  while  the  pressure 


SURGICAL   OPERATIOXS.  51 

upon  tlie  blade  carries  it  througli  the  tougher  tissues  vrith  less  exertion. 
When,  however,  a  careful  dissection  is  requii-ed — as  in  clearing  out  the 
axillary  space — the  second  method,  similar  to  that  in  which  a  pen  is  held,  is 
preferable.  It  is  always  necessary  to  stretch,  and  thus  steady,  the  integu- 
ment with  the  thumb  and  index  of  the  other  hand  when  an  incision  is 
made  (Fig.  110). 


Irrigation  may  be  continuous  or  interrupted,  owing  to  the  demands 
of  each  case.  Operations  in  the  joints,  or  near  an  nicer,  sinus,  abscess, 
or  any  inflamed  area,  require  exceptional  precautions.  In  clean  opera- 
tions, such  as  an  amputation  in  continuity,  Avhere  no  inflammation  exists, 
or  the  removal  of  a  benign  tumor,  etc.,  interrupted  irrigation,  or  flushing 
the  wound  thoroughly  every  five  minutes,  will  keep  the  wound  aseptic. 

In  an  operation  which  opens  into  any  of  the  cavities  the  irrigator  can 
not  be  used  for  fear  that  the  solution  may  remain,  and  poisoning  result 
from  absorption  of  the  corrosive  sublimate.  Asepsis  must  be  here  secured 
by  mopping  the  surfaces  of  the  wound  with  wet  sponges.  The  stronger 
sublimate  solutions  can  not  be  brought  in  contact  with  the  eye  without 
annoying  inflammation  resulting. 

The  methods  of  TicBmostasis  differ  in  different  parts  of  the  body,  and 
Tinder  varying  conditions.  Thus,  when  amputating  an  extremity  ren- 
dered bloodless  by  Esmarch's  elastic  bandage,  or  when  the  limb  has  been 
elevated  and  an  ordinary  tourniquet  adjusted,  the  ligatures  are  not  ap- 
plied until  the  wound  is  completed  and  the  bone  divided.  On  the  other 
hand,  when  operating  without  the  tourniquet,  it  is  essential  that  each 
bleeding  point  be  secured  as  soon  as  possible  ;  or  that  the  vessels  be  tied 
"with  double  ligatures  and  afterward  divided  between  them.  This  excel- 
lent practice  not  only  serves  to  prevent  excessive  loss  of  blood,  but 
keeps  the  wound  dry  and  clear,  enabling  the  operator  to  make  a  more 
intelligent  dissection.  In  order  to  be  explicit  in  detail,  take,  for  exam- 
ple, any  major  amputation  by  the  bloodless  method.  The  flajDS  having 
been  made,  the  soft  tissues  are  cut  clearly  thi-ough,  and  the  bone  divided 
with  the  saw.  The  stump  is  now  thoroughly  cleansed  by  irrigation,  the 
cut  surfaces  dried  off  with  sponges,  and  the  ends  of  the  vessels  sought 
for  in  their  known  positions.  In  picking  up  the  end  of  an  artery  or  vein 
it  is  necessary  to  exclude  all  other  tissues,  and  especially  the  nerves, 
from  the  grasp  of  the  forceps  and  ligatures.  To  accomplish  this,  catch 
the  vessel  by  one  edge  with  a  delicate-pointed  forceps,  draw  it  out  from 
the  wall  of  the  wound,  and  from  its  sheath,  and  Avith  a  dull  insti'ument, 
such  as  the  point  of  a  grooved  director,  strip  the  tissues  backward  from 
the  artery  until  about  one  fourth  of  an  inch  of  the  tube  is  exposed.  A 
large,  round-pointed  forceps  (Fig.  82)  may  now  be  applied,  and  the  liga- 


52 


A  TEXT-BOOK   ON   SURGERY. 


tiire  tied  over  this.  The  ligature  should  be  appropriate  to  the  size  of  the 
vessel  to  be  secured,  as  heretofore  given.  In  making  the  knot,  one  of 
two  methods  may  be  selected,  namely,  the  single  knot,  or  the  double  or 
friction  knot.  The  former  is  so  well  represented  in  Fig.  Ill  that  it  will 
not  require  description.  A  little  practice  wUl  show  the  superiority  of 
this  over  Xh^  false  knot  shown  in  Fig.  112,  w-hich  is  more  apt  to  slip.     In 


Fig.  111.— Eeef  knot. 


Fig.  112.— False  knot. 


Fig.  113.— Friction  knot. 


the  friction  or  double  knot  (Fig.  113)  the  end  of  one  side  is  passed  twice 
under  and  over  the  other  for  the  first  loop,  instead  of  once,  as  just  given. 
When  the  ends  of  the  ligature  are  drawn  upon,  and  the  vessel  con- 
stricted, the  first  knot  holds  without  danger  of  slipping  until  a  second 
single  knot  is  added  to  it.  As  to  the  ai^pUcation  of  one  or  the  other  of 
these  loops,  the  single  knot  will  suffice  for  all  vessels  which  are  freely 
exposed  and  superficial,  where  the  surgeon  can  be  assured  that  the  first 
turn  holds  fast  until  the  second  has  secured  it.  In  deep  wounds,  where 
the  knot  must  be  run  down  with  the  finger-tips,  as  in  the  deligation  of 
an  artery  in  its  continuity,  the  double  knot  should  be  preferred.  After 
being  tied,  the  ends  are  cut  with  the  scissors  about  one  quarter  of  an  inch 
from  the  knot.  As  to  how  much  force  it  is  necessary  or  proper  to  exert 
in  the  application  of  a  ligature  to  an  artery  it  is  impossible  to  say.  This 
point  will  be  fully  discussed  in  the  chapter  on  Surgery  of  the  Arteries. 
It  is  always  better  to  use  too  much  than  too  little  force,  for  one  of  the 
greatest  possible  annoyances  to  the  operator  is  to  be  compelled  to  open  a 
wound.  When  a  vessel  can  not  be  otherwise  found,  its  presence  may  be 
demonstrated  by  squeezing  the  flap  and  jDressing  out  the  small  quantity 
of  blood  remaining  in  it.  In  this  way  all  vessels  of  any  size  or  conse- 
quence can  be  secured  before  the  tourniquet  is  loosened.  Before  this 
is  done  the  wound  should  be  thoroughly  irrigated,  the  flaps  opened  and 
filled  with  squeezed-out  antiseptic  sponges,  the  whole  covered  with  warm 
sublimate  towels,  and  compression  made  with  the  hands  while  the  stump 
is  elevated  and  the  tourniquet  loosened.  After  five  or  ten  minutes  the 
wound  is  opened  and  the  sponges  removed,  one  at  a  time.  Any  bleed- 
ing points  which  may  have  been  overlooked  will  now  be  easily  seen,  and 
should  be  grasped  with  the  forceps  and  tied.  In  applying  the  forceps 
to  these  points  it  is  impossible  to  exclude  the  tissues  immediately  around 
the  vessels  from  the  grasp  of  the  instrument  and  the  ligature.  When 
using  the  broad-shouldered  forceps,  if  the  catgut-thread  is  tied  around 
the  jaws  of  the  instrument  and  the  loop  tightened,  the  thread  slides 
along  to  the  tip,  and,  in  slipping  off  to  constrict  the  bleeding  vessel, 
pushes  the  other  soft  tissues  to  one  side.     In  tying  such  a  ligature  care 


SURGICAL    OPERATIONS.  53 

must  be  taken  not  to  pull  upon  one  end  vdth  more  force  than  the'  other, 
for  by  so  doing  the  vessel  is  torn  off  ;  and  also  to  apply  the  force  to  the 
thread  on  a  level  v.-ith  the  tip  of  the  forceps,  for  if  this  is  not  done  the 
vessel  is  also  pulled  out  of  the  wound  and  torn  away. 

When  all  hsemorrhage  has  ceased,  except  the  slight  oozing  which  may 
occur  at  any  part  of  the  wound,  and  always  does  come  from  the  bone, 
the  irrigation  is  repeated,  and  a  drainage-tube  (the  bone-drains  are  pref- 
erable) inserted  at  each  angle  of  the  wound  at  a  point  wjiere,  with  the 
part  in  the  position  in  which  it  must  rest  during  repair,  the  drainage  of 
serum  or  other  fluid  will  be  free  and  uninterrupted.  The  flajis  are 
adjusted  by  inten-upted  catgut  sutures,  and  safety-pins  placed  in  the 
ends  of  the  tubes  which  project.  The  nozzle  of  the  irrigator  is  now 
placed  in  the  tube  of  one  side  and  then  the  other,  and  the  wound  dis- 
tended with  1  to  3,000  sublimate,  which  is  then  thoroxighly  pressed  out 
and  the  dressing  applied  as  follows  : 

A  strip  of  sublimate  gauze  about  two  inches  wide  is  button-holed,  so 
as  to  fit  over  each  of  the  tubes,  and  laid  over  the  line  of  sutures,  and  on 
top  of  this  several  other  pieces  of  the  same  size.  The  stump  and  thigh, 
up  to  the  groin,  is  now  enveloped  in  sublimate  gauze  in  layers  until  the 
whole  is  about  one  inch  thick.  Over  this  a  layer  of  absorbent  cotton  of 
the  same  thickness,  and  outside  of  this  a  sheet  of  protective  which  has 
been  dipped  in  sublimate  solution.  The  whole  is  held  in  position  by 
bandages,  which  should  be  put  on  tight  enough  to  hold  the  muscles  quiet 
and  arrest  all  oozing  from  the  wound,  and  yet  not  press  the  flaps  against 
the  end  of  the  bone,  and  thus  cause  sloughing.  Such  is  the  permanent 
antiseptic  dressing,  which  remains  unmolested  unless  pain  or  a  rise  in 
temperature  indicates  that,  despite  the  precautions  taken,  inflammation 
and  swelling  or  sepsis  have  occurred,  or  until  the  discharge  from  the 
wound  has  soaked  through  the  dressings  and  has  become  offensive,  hav- 
ing undergone  decomposition  beyond  the  zone  of  antisepsis. 

The  after-treatment  of  a  patient  who  has  undergone  a  major  surgical 
operation  will  depend  a  good  deal  upon  the  character  of  the  operation. 
The  immediate  care  should  be  to  maintain  the  vitality  of  the  tissues, 
which  has  been  endangered  by  the  shock  of  the  procedure  and  loss  of 
blood,  by  judicious  stimulation  and  relief  from  pain.  A  hypodennic 
injection  of  morphia  guarantees  relief  from  pain.  If  the  pulse  is  weak, 
and  the  temperature  low,  an  enema  of  whisky  or  the  hypodermic  admin- 
istration of  this  agent  will  stimulate  the  heart,  while  hot  ajiplications 
will  aid  in  the  restoration  of  the  normal  temi^erature.  One  important 
point  must  not  be  lost  sight  of — namely,  that  after  a  surgical  operation 
there  is  always  a  reaction,  accompanied  by  increased  heart-action  and 
elevation  of  temperature,  and  that  while  stimulants  are  often  necessary 
in  the  stage  of  depression,  their  administration  should  be  guarded,  so 
that  they  may  not  add  to  the  fever  of  reaction. 

As  long  as  the  effects  of  the  anaesthesia  last,  a  trained  attendant 
should  remain  at  the  bedside  to  guard  against  the  danger  of  asphyxia  in 
case  of  vomiting,  to  restrain  the  patient  from  unnecessary  movements, 
or  it  may  be  to  guard  against  haemorrhage. 


CHAPTER  V. 

INFLAMMATIOjV. 

Literally  defined,  inflammation  means  a  preternatural  heat.  In 
surgery  it  is  applied  to  a  condition  of  animal  tissues  which  are  undergo- 
ing certain  disturbances  in  nutrition  which  produce  locally  abnormal 
hypercBmia,  heat,  redness,  swelling,  and  pain.  Taken  singly,  none  of 
these  features  of  the  inflammatory  process  can  be  said  to  exjDress  this 
morbid  condition  ;  they  must  all  be  present. 

It  is  well  known  that  each  of  these  conditions  may  exist  without 
inflammation,  and,  indeed,  some  of  them  are  present  in  purely  physio- 
logical processes. 

Thus,  vascular  tumors  and  the  dilated  capiUary  net-works  of  certain 
forms  of  nsevi,  though  characterized  by  permanent  hypersemia  and  red- 
ness, are  not  inflammatory  conditions.  Blushing,  which  is  associated  as 
part  of  the  expression  of  certain  emotions,  is  accompanied  with  no  other 
symptom  of  a  morbid  process  than  that  of  redness.  The  temperature  of 
the  blood  in  the  hepatic  vein  in  conditions  strictly  physiological  has 
been  registered  as  high  as  107°  F.,  and  this  extraordinary  heat  is  not 
inflammatory. 

Swelling  is  present  in  non-inflammatory  processes,  such  as  oedema  and 
emphysema,  while  pain  is  not  infrequent  in  certain  neuroses,  where  all 
other  symptoms  of  inflammation  are  absent.  Whether  the  cause  of  inflam- 
mation be  one  of  direct  injury  and  irritation  of  a  part,  or  whether  it  be 
diie  to  lesions  of  the  inhibitory  nerves  or  trophic  centers  remote  from  the 
local  expression  of  the  morbid  process,  the  pathological  changes  are  prac- 
tically the  same.  The  activity  and  violence  of  the  jjrocess  will  depend  in 
part  upon  the  character  and  extent  of  the  injury,  the  presence  of  certain 
forms  of  micro-organisms  or  animal  poisons,  as  well  as  utjou  the  anatom- 
ical character  of  the  part  involved,  together  with  the  ability  of  the  tissues 
to  resist  death,  and  to  repair  the  damage  inflicted. 

The  study  of  the  phenomena  of  inflammation  may,  Avdth  propriety,  be 
arranged  in  the  following  order :  1,  irritation ;  2,  contraction ;  and  3, 
dilatation  of  the  vessels  ;  4,  acceleration  of  the  current  and  hypersemia ; 
5,  retardation,  partial  or  complete ;  6,  redness  ;  7,  swelling  ;  8,  heat ;  9, 
pain  ;  10,  escape  of  vessel  contents ;  11,  general  cell-proliferation  ;  12, 
formation  of  pus  ;  13,  reorganization  and  repair  ;  14,  cicatrization. 

It  is  known  that  when  a  vascular  living  animal  tissue  is  subjected  to 
irritation,  the  vessels  in  the  zone  of  irritation  undergo  an  instant  con- 


1 


INFLAMMATION.  55 

traction,  and  almost  instantly  thereafter  become  abnormally  dilated. 
The  cause  of  this  contraction  is  supposed  to  be  due  to  stimulus  of  the 
vaso-motor  nerves,  while  the  dilatation  is  exjDlained  as  due  to  paralysis 
of  the  vessel-walls  from  injury  to  the  inhibitory  nerves,  to  changes  in  the 
walls  proper,  as  the  result  of  irritation,  or  to  overstretching  or  rupture  of 
the  connective  and  elastic- tissue  filaments  which  support  the  vessels  from 
without.  With  these  changes  in  the  vessels  which  occur  in  such  rapid 
succession,  the  blood-current  is  accelerated  ;  hypersemia  ensues,  and  this, 
in  turn,  is  followed  by  more  or  less  complete  blood-stasis.  This  last  con- 
dition is  most  marked  in  the  center  of  the  inflamed  zone,  and  when  com- 
plete arrest  occurs  it  is  first  seen  here.  At  this  stage  leucocytes,  in 
greatly  increased  proportion  in  the  blood,  appear  in  the  venules  and 
capillaries,  to  the  walls  of  which  they  adhere,  and  through  which  they 
are  seen  to  pass  by  active  amoeboid  movement,  until  they  wander  free  in 
the  intervascular  spaces  (wandering  or  emigrant  cells). 

The  bi-concave  disks  and  liquor  sanguinis  also  escape  in  the  wake  of 
the  white  corpuscles.  It  is  held  that  the  points  of  escape  are  in  the  inter- 
vals between  the  flat  cells  of  which  the  vessel-walls  are  composed.  In  the 
area  of  complete  stasis  emigration  does  not  occur. 

Stasis  is  very  ]5robably  due  to  a  pathological  change  in  the  walls  of  the 
vessels,  which  in  turn  induces  in  the  blood  of  the  inflamed  area  certain 
changes  whereby  the  "  normal  equilibrium  existing  between  the  blood  and 
the  containing  vessels,  which  is  physiologically  essential  to  the  integrity 
of  the  circulation,  is  impaired  or  lost."  The  presence  of  the  white  corpus- 
cles should  not  be  overlooked  in  seeking  for  an  explanation  of  stasis,  for 
paraglobulin,  the  coagulation  factor  of  the  blood,  is  the  normal  property 
of  the  leucocytes,  and,  as  stated,  they  are  present  in  increased  numbers. 

Redness,  swelling,  local  increase  of  temperature  and  pain,  occur  with, 
and  as  a  result  of,  inflammatory  hypera3mia.  The  discoloration  is  due  to 
hsematin  in  increased  qiiantity,  not  only  within  the  vessels,  but  in  the 
spaces  between  the  capillaries.  Tumefaction  is  due  to  increased  blood- 
supply,  to  extravasation,  dilatation  of  the  lymph-channels,  increase  of 
lymph,  and  cell-iDroliferation.  Abnormal  heat  is  caused  by  increased  cell 
activity  and  the  abnormal  condition  of  the  blood  within  the  inflamed  area, 
while  pain  is  due  to  pressure  upon  the  end  organs  of  the  sensory  nerves. 

With  the  appearance  of  the  leucocytes  in  increased  numbers,  and  the 
escape  of  these  into  the  intervascular  spaces  of  the  inflamed  area,  cell- pro- 
liferation occurs,  resulting  in  the  formation  of  a  common  embryonic  tissue. 

Examined  microscopically,  this  embryonic  tissue  is  seen  to  be  com- 
posed of  protoplasmic  bodies  or  cells,  spherical  in  shape,  or  slightly 
polygonal  from  reciprocal  pressure,  varying  in  size  from  about  -g-jVir  to 
■^-^  of  an  inch,  and  often  larger  than  this.  They  may  be  nucleated,  but 
usually  appear  as  slightly  cloudy  or  granular  protoplasmic  bodies  with 
no  distinct  nucleus  or  nucleolns. 

Of  the  normal  cells,  which  are  most  active  in  proliferation,  and  there- 
fore chiefly  involved  in  the  formation  of  the  new  tissue,  it  is  difficult  in 
the  present  condition  of  pathological  research  to  say.  The  followers  of 
Cohnheim  hold  with  him  that  the  leucocyte  is  the  chief  factor  in  this 


56  A  TEXT-BOOK   ON   SURGERY. 

process.  Others  look  to  the  connective-tissue  cells  as  of  equal  impor- 
tance with  the  leucocytes  ;  while  a  third  theory  is  that  all  cells  of  a  part 
responding  to  the  general  stimulus  of  the  inflammatory  process  undergo 
proliferation,  and  that  the  embryonic  tissue  is  a  common  product. 

From  this  it  is  probably  a  safe  and  wise  deduction  to  consider  that 
the  chief  role  in  the  inflammatory  jarocess  is  played  by  the  leucocytes  ; 
that  they  not  only  proliferate,  but  by  their  presence  stimulate  active 
nutritive  changes  and  proliferation  in  the  cells  in  general,  and  that  the 
embryonic  tissue  is  in  truth  a  product  of  all  these  elements,  varying  in 
degree  of  fertility.  This  conclusion  seems  rational,  since  the  normal 
role  of  every  cell  element  of  the  body  is  one  of  proliferation  and  the 
formation  of  a  new  element  to  replace  one  which  has  flnished  its  life- 
history  ;  and  it  seems  reasonable  to  infer  that  a  more  rapid  proliferation 
of  the  same  cells  would  occur  under  conditions  of  increased  hypersemia 
and  nutrition. 

The  products  of  the  inflammatory  process  may  be  organized  into  a 
permanent  tissue,  or,  failing  in  this,  may  perish.  With  the  tissues  of  the 
individual  possessing  the  power  to  resist  destruction  the  reparative  pro- 
cess is  rapid.  Septic  micro-organisms  do  not  find  conditions  favorable 
to  their  development,  and  suppuration  does  not  occur.  The  peculiar 
type  of  the  new  tissue  is  probably  determined— (1)  By  the  nature  of  the 
original  cell  from  which  it  sprung.  Thus  the  experiments  of  Goujon 
showed  that  the  medullo-cells  and  myeloplaxes  of  bones  in  young  ani- 
mals, when  injected  into  the  muscular  tissue,  developed  into  bone  even 
remote  from  the  parent  tissue.  (2)  By  the  location  and  function  of  the 
new  tissue,  as  is  shown  in  the  development  of  exostoses  from  a  common 
embryonic  tissue  near  the  insertion  of  tendon  into  bone. 

When  the  inflammatory  process  is  rapid  and  severe,  the  new  tissue 
perishes  suddenly,  and  with  it  occurs  the  rapid  death  or  gangrene  of 
the  tissues  involved.  Under  milder  conditions  the  supply  of  nutrition 
may  be  more  gradually  diminished,  and  the  embryonic  ceUs  undergo 
fatty  degeneration  and  absorption.  It  is  then  said  to  have  undergone 
resolution.  Again,  and  not  uncommonly,  the  cells  of  the  new  tissue, 
partly  granular  and  partly  unchanged,  are  found  floating  in  a  fluid,  the 
liquor  puris. 

Symptoms. — In  the  milder  forms  of  inflammation  no  symptoms  may 
be  observed  beyond  the  local  disturbance.  In  other  and  severer  types 
the  elevation  of  temperature  is  often  well  marked,  and  not  infrequently 
preceded  by  or  accompanied  with  a  series  of  rigors,  or  a  pronounced  chill. 
This  is  especially  apt  to  occur  in  erysipelas,  dermatitis,  and  any  form  of 
phlegmon.  The  pulse  is  accelerated,  the  tongue  is  dry  and  coated,  thirst, 
anorexia,  and  headache  follow  in  the  train  of  symptoms  which  are  com- 
mon in  septic  fever — the  fever  of  inflammation. 

Treatment. — The  measures  to  be  employed  are  local  and  general.  The 
immediate  indication  is  rest  of  the  part  inflamed.  If  one  of  the  extremi- 
ties is  involved,  an  elevated  position  by  means  of  a  swinging  cradle  (Fig. 
114),  or  upon  a  pillow,  will,  as  a  rule,  give  the  gi'eatest  degree  of  comfort, 
especially  in  cases  where,  by  reason  of  the  swelling,  the  circulation  in  the 


INFLAMMATION. 


57 


veins  beyond  the  infiltrated  j^ortion  is  interfered  with.  In  such  con- 
ditions a  flannel  bandage,  properly  applied  from  the  end  of  the  extremity 
up  to  the  inflamed  area,  will  be  advisable.  If  the  swelling  becomes  so 
intense  as  to  threaten  gangrene,  or  even,  by  excessive  tension  of  the  part, 


Fig.  114. — Fluhi-er's  swinging  cradle  (Mt.  Sinai  Hospital). 

to  give  extreme  pain,  free  incisions  should  be  made  parallel  with  the  axis 
of  the  limb,  extending  well  through  to  the  deep  fascia,  and  through  this 
if  necessary.  These  incisions,  made  so  as  not  to  divide  the  vessels,  should 
be  left  open  and  treated  with  strict  antisepsis. 

Blood-letting,  either  by  venesection  or  by  leeches,  or  scarification  and 
cupping,  are  to  be  employed  in  certain  selected  cases.  In  plethoric  indi- 
viduals, with  high  febrile  movement  and  bounding  pulse,  venesection 
may  be  done  with  marked  and  immediate  benefit.  The  operation  should 
be  performed  in  the  median  cephalic  vein  as  follows  (Fig.  115) :  Apply  a 
bandage  around  the  middle  of  the  upper  arm  suflBciently  tight  to  occlude 
the  veins,  but  not  to  arrest  the  arterial  circulation.  Produce  local  anses- 
thesia  at  the  point  of  incision  by  injecting  from  5  to  10  minims  of  4-per- 
cent cocaine  beneath  the  skin  in  the  line  of  the  median  cephalic  vein  {not 
median  basilic).  Ether  spray,  or  salt  and  ice,  may  be  employed  if  cocaine 
can  not  be  obtained.  Make  an  incision  from  a  half -inch  to  one  inch  long, 
varying  with  the  amount  of  subcutaneous  fat,  and  directly  over  the  vein 
untn  it  is  well  exposed.  With  a  curved  pair  of  scissors  now  make  a 
valvular  slit  about  half  through  the  vein.  The  amount  of  blood  to  be 
withdrawn  will  be  determined  by  the  impression  made  upon  the  radial 
pulse  of  the  opposite  arm,  and  in  part  by  the  sensation  of  the  patient. 
From  8  to  16  ounces  will  usually  suffice. 


58 


A  TEXT-BOOK   ON  SURGERY. 


When  ready  to  arrest  the  flow,  place  a  pellet  of  absorbent  cotton, 
moistened  in  1  to  3,000  sublimate,  over  the  wound,  hold  it  firmly  here, 
and  then  remove  the  ligature.  A  piece  of  sublimate  gauze  is  now  laid 
over  the  wound,  and  held  in  place  by  a  moderately  tight  bandage. 

If  leeches  are  to  be  employed, 
from  six  to  a  dozen  or  more 
should  be  applied  directly  to 
the  inflamed  area.  If  a  drop  of 
blood  is  drawn  out  by  the  prick 
of  a  needle,  or  warm  milk 
dropped  on,  they  will  take  hold 
more  readily.  Once  attached, 
they  should  be  allowed  to  drop 
off  of  their  own  accord.  If  the 
oozing  from  the  wound  is  too 
prolonged,  it  can  be  arrested  by 
a  sublimate  comj)ress. 


Fig.  116. — Ten-bladed  scarificator. 

Scarification  is  now  rarely 
practiced,  since  freer  incisions 
are  to  be  x^referred.  When  per- 
formed, it  consists  of  making 
a  series  of  small  cuts  into  or 
through  the  inflamed  integu- 
ment by  means  of  a  number  of 
lancets,  driven  by  a  sjDring  with 
almost  painless  rapidity  (Fig. 
116). 

Compression  applied  to  the 
main  artery,  going  to  the  part 
inflamed  at  a  point  removed  from  the  zone  of  inflammation,  is  impracti- 
cable and  of  doubtful  benefit.  The  constriction  of  the  artery  without 
also  partly  occluding  the  vein  is  scarcely  possible  except  by  digital 
compression,  or  the  use  of  the  pole-compress,  shown  in  the  treatment  of 
aneurism. 

The  local  application  of  cold  is  of  great  benefit,  and  usually  affords 
much  comfort  in  the  treatment  of  inflammation.  One  of  the  most  useful 
and  cleanly  methods  of  applying  it  is  to  place  crushed  ice  in  the  well- 


FiG.  115. — (Modified  from  Esmareh.) 


INFLAMMATION 


59 


known  rubber  ice-bag  (Fig.  117).  When 
these  can  not  be  obtained,  the  blad- 
ders and  stomachs  of  animals,  jDroperly 
cleansed,  can  be  substituted.  Ice-water 
can  be  employed  by  means  of  an  i/rri- 
gator,  with  a  stop-cock  to  regulate  the 
flow,  or  by  placing  a  pitcher  or  basin 
containing  the  water  immediately  above 
the  part,  and  dipping  into  this  a  twist  of 
soft  cotton  or  linen  cloth,  allowing  one 
end  to  hang  directly  over  the  inflamed 
area  in  such  a  position  that  the  constant 
drip  will  fall  upon  it  (see  Fig.  7).     Or  a 


Fn,    117  — (Fium  iMnarch.) 


Fig.  118. — (Modified  from  Fischer.) 


60  A  TEXT-BOOK   ON   SURGERY. 

piece  of  tubing  may  be  used  as  a  siplion  to  the  flow,  regulated  by  a 
safety-pin  clamp. 

A  coil  of  rubber  tubing  wound  around  or  upon  an  inflamed  surface, 
through  which  cold  water  is  allowed  to  run  continuously,  is  an  effective 
method  of  applying  cold  (Fig.  118).  This  apparatus  is  objectionable  in 
some  instances  on  account  of  its  weight.  Submerging  an  inflamed  ex- 
tremity in  a  vessel  of  cold  water  m^ay  also  be  efficacious. 

Heat  may  be  applied  by  employing  the  same  apparatus  as  for  cold.  The 
ice-bag  may  be  filled  with  hot  water,  or  hot  irrigation  used.  Cloths  rinsed 
in  hot  water  and  laid  over  the  inflamed  surface  is  one  of  the  readiest 
and  best  methods  of  utilizing  heat  in  the  treatment  of  inflammation. 
Poultices  of  flaxseed-meal,  or  of  bread,  aiDi)lied  and  kept  moist  and 
warm,  are  also  useful  local  aijplications.  A  poultice  used  on  a  broken 
surface  should  be  made  with  1  to  10,000  sublimate  solution. 

In  determining  whether  heat  or  cold  will  be  used  in  any  given  case, 
the  surgeon  must  be  guided  in  part  by  the  sensibility  of  the  jiatient,  for 
that  which  is  most  grateful  to  the  part  inflamed  will  usually  produce  the 
most  satisfactory  results. 

Counter  irritants,  such  as  blisters,  sinapisms,  or  the  cautery,  are  use- 
ful at  times  in  the  therapy  of  inflammation,  especially  in  chronic  pro- 
cesses in  the  joints  and  deeper  tissues. 

Internal  Medication. — As  far  as  the  constitutional  treatment  of  inflam- 
mation is  concerned,  each  case  will  be  a  law  unto  itself.  In  the  stronger 
and  plethoric  patients  a  saline  or  a  calomel  purge  is  indicated  in  the 
beginning  of  the  jjrocess,  and  restricted  diet  should  be  insisted  upon. 
For  the  more  feeble  class  of  cases,  tonics,  cod-liver  oil,  good  air,  and  well- 
directed  nourishment  are  essential.  To  counteract  the  high  febrile  move- 
ment and  rapid  pulse,  antipyrine  in  doses  of  gr.  x  to  xx,  repeated  in 
two  hours,  or  antifebrine,  gr.  v  to  x,  are  excellent  remedies.  Aconite 
tincture,  gtt.  ij,  and  one  drop  additional  every  half-hour  until  the  pulse 
falls,  is  also  to  be  recommended.  Quinia  in  doses  of  gr.  x  twice  a  day, 
or  even  oftener,  in  case  of  chills  or  rigors.  Morphia,  or  one  of  the  hyp- 
notics, should  be  given  when  positively  indicated  by  the  patient's  suffer- 
ings from  pain  or  loss  of  sleep. 

Suppuration — Micrococci — Bacilli  —  Bacteria  —  Septicwmia — Pyce- 
mia — Traumatic  Fever. — Inflammation  without  sepsis  is,  as  just  stated, 

practically     a     physiological     process. 
^  When,  however,  by  direct  infection — 

f  •fo'f'J  the  wounded  tissues  being  exposed  to 

^  ^  ' ^^  "'^  the  air — or  indirect  infection,  through 
'°°/'^^°.  s  imbibition,  inspiration,  or  absorption 
'°"  „/  if  from  an  abraded  surface,  these  patho- 
"^.coo'"  ,l'o  genie  micro-organisms  enter  the  blood- 

'  «/"  °"°  "<'  current  and  find  their  way  to  the  in- 

flamed area,  suppuration  occurs. 
lyoge-    streJto^ocL^'pyo-  '^^^  idiVLx^  of  orgauisms  which  are 


nes. 


modiSdTomLan-'      S)"  ^fModifiod      ^^^^i^fly  factors  in  this  process  are:    (1) 
^erer.)  from  Landerer. )       Staphylococcus  pyogenes   aureus   (the 


INFLAMMATION. 


ei 


pus-makiug,  gold-colored,  bunch  [grape]  coccus)  (Fig.  119) ;  (2)  Staphy- 
lococcus pyogenes  albus  (or  white  coccus) ;  (3)  Streptococcus  pyogenes 
(or  chain  coccus)  (Fig.  119  a). 

The  white  cocci  are  not  so  frequently  met  with  as  the  gold-colored 
fimgi.  Under  the  microscope  both  of  these  varieties  appear  alike,  and 
it  is  only  in  pure  cultures  that  the  yellow  hue  is  observed,  by  which  the 
Staphylococcus  pyogenes  aureus  is  recognized  fi'om  the  white  variety. 

In  addition,  in  very  foul  pus  and  putrefying  masses  there  is  found 
a  rod-shaped  organism  known  as  the  Bacillus  saprogenes,  or  bacteri- 
um of  putrefaction  (Fig.  119  b). 

^ATienever  colonies  of  Sta- 
2)hylococci  and  Streptococci  are 
established  in  the  inflamed  areas, 
liquefaction  of  the  contiguous 
tissues  takes  place,  the  quantity 
of  lymph  and  serum  is  aug- 
mented, and  thus  the  liquor 
puris  is  supplied.  In  this  fluid 
float  the  dead  and  dying  leuco- 
cytes, embryonic  cells,  swarms 
of  micro-organisms,  and  shreds 
of  broken-down  connective  and 
other  tissues. 

By  the  rapid  accumulation 
of  pus,  pressure  upon  and  con- 
densation of  the  surrounding 
tissues  is  greatly  increased,  and 
this,  together  with  the  rapid  de- 
velopment of  a  peripheral  em- 
bryonic tissue,  forms  the  limiting  membrane  or  abscess-Lcall.  Not  in- 
frequently when  the  distention  is  raj)id  the  vitality  of  the  contiguous 
tissues  is  sacrificed  by  the  occlusion  of  the  outlying  veins  and  arterioles. 
Coagulation  in  the  veins  {t7irombosis)  is  of  common  occurrence. 

Pus. — In  its  recent  state,  pus  is  a  cream-like  fluid,  in  specific  gravity 
varying  from  1'020  to  1-040,  and  at  times  higher.  In  closed  cavities  in 
the  tissues  it  is  usually  alkaline  in  reaction,  but  when  exposed  to  the 
atmosphere  (and  in  some  instances  even  within  the  tissues,  where  it  is 
protected  from  the  air)  it  becomes  acid.  Chemically  it  may  contain  para- 
globulin,  myosin,  fatty  acids,  leucin,  tyrosin,  cholesterin,  chloride  of 
sodium,  and  phosphates.  Healthy  pus  is  odorless,  but  when  decompo- 
sition has  occiirred  the  odor  is  often  exceedingly  offensive. 

Examined  microscopically,  numerous  corpuscles,  varying  in  size  from 
^^^Q  to  3^0"  of  an  inch,  are  seen  floating  in  a  transparent  fluid — the  liquor 
puris.  These  cells  have  no  limiting  membrane,  contain  one  or  several 
nuclei,  and  at  times  a  number  of  fine  granules,  and  can  not  be  differen- 
tiated from  the  white  blood-corpuscle  or  the  common  embryonic  cell. 

Another  cell-like  body  found  in  jjus,  especially  in  older  abscesses,  or 
where  a  chronic  inflammatory  process  has  occurred,  is  the  granular  cor- 


■  ■■  .■.^^^^ 

1^;. 

n^ 

%i  '' 

'i^^^ 

W% 

'^^^hbH 

jffl  >J-'   -    .- 

*^^Hb^ 

^  ''a 

tS^KSk 

i^'''l  . 

Fig.  119  b.— (After  Koch.) 


62 


A  TEXT-BOOK   ON  SURGERY. 


puscle,  or,  as  it  is  more  commonly  called,  the  compound  granular  cor- 
puscle. The  pus-corpuscles  proper  are  leucocytes  and  dead  embryonic 
tissue-cells.  The  compound  granular  corpuscles  are  made  up  of  an  aggre- 
gation of  granules,  the  detritus  of  leucocytes,  embi'yonic  tissue,  or  other 

cells,  which  have  un- 
dergone fatty  or  gran- 
ular metamorphosis. 
These  adhere  together 
in  spherical  or  oval 
masses  of  all  sizes, 
often  as  large  as  a 
dozen  pus-cells  togeth- 
er, or  the  granules  may 
float  free  in  the  liquor 
puris.  The  differentia- 
tion of  these  elements 
is  not  difficult.  Upon 
the  addition  of  acetic 
acid  the  jaus  -  corpus- 
cles become  swollen, 
and  lose  their  granu- 
lar, cloudy  appearance, 
while  their  nuclei,  oth- 
erwise scarcely  recog- 
nizable, stand  out  in 
strong  relief.  Acetic 
acid  does  not  affect  the  gramdar  corpuscle,  which,  however,  is  soluble  in 
ether.  Pus-corpuscles  jjroper  are  at  times  endowed  with  the  amoeboid 
movement.  This  is  only  true  of  the  white  blood-cell,  which  has  not  yet 
perished.  The  dead  embryonic  cells  do  not  possess  the  power  of  motion. 
These  various  elements  of  pus,  as  well  as  the  cholesterin  crystals, 
which  are  sometimes  met  with,  are  shown  in  Fig.  120. 

Pus-corpuscles  and  the  liquor  puris  from  all  acute  abscesses,  whether 
communicating  with  the  atmosphere  or  not,  contain  also  one  or  more  of  the 
micro-organisms  above  described 
(Pigs.  120  a  and  120  b).  In  rare 
instances  pus  loses  its  creamy- 
white  color  and  assumes  a  bluish 
tint,  due  to  the  presence  of  a  ba- 
cillus known  as  the  "bacillus  of 
blue  pus."  This  form  of  pus  is 
not  septic  to  a  dangerous  degree. 
All  of  these  organisms  usually 
disappear  from  abscesses  of  long 
standing  —  the  cold  abscesses. 
The  chief   significance  of    these 

tm\g\— Staph,  pyo.  aur.,  Staph,  pyo.  alb.,  Strepto.  pyo.— is  that  they 
give  to  pus  a  septic  power,  which  pus  free  from  these  elements  does  not 


Fig.  120. — (Modified  from  Thomas.)  a,  Compound  granular  corpus- 
cles. I),  Crystals  of  cholesterin.  c,  Pus-ceils,  d,  Same  after 
addition  of  acetic  acid. 


cP^o^ 


o^ 


=-"^     ^' 


FiQ  1 20  A  — Pus  fiom  an  leute  ab 
seesi,  showint;  pus  cells,  shreds 
of  broken  down  connective  tis- 
sue, and  micrococci.  (After 
Landerer. ) 


Pig  120  b— Bi- 
ciUi  ot   blue 

£us      (Alter 
andcrer.) 


INFLAMMATION. 


63 


possess.  As  before  stated,  pus-corijuscles  may  disappear  by  granular 
metamorphosis,  the  liquor  piu'is  is  carried  off  by  the  vessels,  and  in 
many  abscesses  of  long  standing  nothing  remains  but  a  half-dried  mass 
of  cheesy-looking  granular  matter. 

When  pus  collects  in  any  part  of  the  body  in  a  recognizable  quan- 
tity, such  collection  is  called  an  abscess.  If  it  is  well  defined,  held  in 
a  given  position  by  a  limiting  membrane  or  wall,  it  is  a  circumscribed 
abscess,  and  diffuse  when  it  widely  infiltrates  the  tissues.  A  rapid 
and  recent  collection  of  pus  is  called  an  acute  abscess  ;  a  slow,  chronic, 
and  ancient  collection,  a  cold  abscess. 

The  limiting  membrane  or  wall  of  a  circumscribed  abscess  is  a  new 
formation  of  inflammatory  origin,  a  granulation  tissue,  studded  with 
cajiillary  loops,  as  in  the  embryonic  tissue  of  a 
wound  undergoing  repair  (Fig.  121).  It  is  in  j)art 
a  pyogenic  inembrajie,  since  it  furnishes  the  dead 
embryonic  cells  which  float  off  into  the  abscess, 
while  the  leucocytes  wander  in  from  the  capillary 
circulation. 

A  diffuse  abscess  results  from  the  property 
which  pus  possesses  under  certain  conditions  of 
dissolving  all  connective  and  embryonic  tissue,  es- 
pecially in  those  suffering  from  impaired  nutri- 
tion. It  thus  meets  with  no  barrier  to  its  progress, 
and  general  infiltration  of  all  the  tissues  of  the  part  involved  occurs. 

A  chronic,  subacute,  or  '•^  cold  abscess  "  differs  from  the  preceding  in 
the  slowness  of  its  development,  and  usually  in  the  absence  of  those 
symptoms  of  local  and  constitutional  disturbance  which  characterize  the 
acute  formation  of  jius.  They  occur,  as  a  rule,  in  diseases  of  bone  and 
joints,  and  in  individuals  of  low  vitalit}-.  Cold  abscess  is  not  infrequent 
after  caries  of  the  spine  and  after  adenitis  of  the  axillary  region. 

Diagnosis. — The  recognition  of  an  acute  abscess  will  depend  w^on  cer- 
tain symptoms  of  a  local  as  well  as  a  constitutional  character.  The  siidden 
rise  of  temperature,  preceded  by  a  pronounced  chill  or  a  series  of  rigors,  are 
symptoms  of  the  formation  of  pus  and  beginning  septic  infection.  The 
local  signs  are  those  of  inflammation,  which  precedes  as  well  as  co-exists 
with  the  pus  formation.  Heat,  pain,  redness,  and  swelling  are  therefore 
among  the  earlier  symjDtoms.  Fluctuation  is  also  present  in  well-advanced 
cases.  The  integument  and  subcutaneous  tissues  about  an  abscess  are 
often  oedematous  and   doughy,  becoming  pale,  and   pitting  under  the 


Fig.  121.- (After  Agne 


Fig.  122. — Exploring-needle  and  syringe. 


finger.  The  positive  test  as  to  the  presence  of  jpus  in  quantity  is  aspira- 
tion. For  this  purpose  the  hypodermic  syringe,  with  an  extra  large  and 
long  needle  (Fig.  122),  is  invaluable.  The  following  precautions  should 
be  practiced :  The  entire  instrument  should  be  thoroughly  cleansed  and 


64  A  TEXT-BOOK   ON   SURGERY. 

submerged  in  a  5-per-cent  carbolic-acid  solution.  The  skin  at  the  point 
to  be  punctured  should  be  washed  with  sublimate  solution  and  ether,  and 
the  needle  pushed  in  so  as  not  to  wound  any  vessels  or  nerves.  If  it 
has  entered  the  cavity,  upon  withdrawing  the  piston  the  pus  will  escape 
into  the  chamber.  The  fluid,  if  any  doubt  exist,  should  then  be  placed 
under  the  microscope.  As  the  needle  is  withdrawn,  the  wound  should 
be  covered  with  sublimate  gauze,  held  in  place  with  a  roller  or  adhesive 
strip. 

In  cold  abscess  the  inflammatory  and  septic  phenomena  are  absent, 
and  fluctuation  may  or  may  not  be  appreciable.  Aspiration  will  deter- 
mine the  character  of  the  swelling. 

Treatment. — AVhen  an  acute  abscess,  either  circumscribed  or  diffuse, 
exists,  it  should  be  freely  evacuated,  and  the  sooner  the  better.  When 
the  abscess  is  situated  in  a  portion  of  the  body  Avhere  there  are  no  impor- 
tant vessels  or  organs  in  danger  of  being  wounded,  a  sharp-pointed, 
curved  bistoury  should  be  carried  through  the  wall,  and  the  cavity 
opened  by  cutting  outward.  These  minor  operations  may  be  done  with 
cocaine  angesthesia.  In  the  neck  or  other  vascular  regions,  or  where  an 
abscess  complicates  a  hernia  or  other  important  viscus,  a  careful  dissec- 
tion should  be  made  from  without  inward.  The  point  of  greatest  impor- 
tance is  to  have  the,  opening  or  openings  in  such  a  position  that  the 
drainage  will  be  from  the  most  dependent  portion  of  the  cavity.  In 
cutting  down  upon  an  abscess  it  is  often  necessary  to  insert  a  small-sized 
aspirator-needle  and  determine  the  exact  distance  to  the  pus.  The 
needle  should  be  left  in  place  as  a  guide.  In  some  of  these  cases,  in 
order  to  avoid  hsemorrhage,  a  very  good  use  may  be  made  of  the  ordi- 
nary dressing-forceps,  by  closing  the  jaws  of  the  instrument  and  j)ushing 
it  through  the  tissues  into  the  pus,  and  then  stretching  the  puiicture  thus 
made  by  forcibly  separating  the  handles. 

As  soon  as  an  abscess  is  oj)ened  the  nozzle  of  the  irrigator  should  be 
introduced,  and  the  cavity  well  washed  out  with  sublimate  (1  to  3,000). 
After  this  rubber  drains  should  be  inserted,  and  a  thick  dressing  of  subli- 
mate gauze  applied. 

When  an  abscess  occurs  in  parts  of  the  body  where  it  is  desirable  to 
avoid  leaving  a  scar,  as  the  neck  or  face,  and  where  the  symptoms  of 
sepsis  are  not  marked,  a  cure  may  be  effected  by  means  of  the  aspirator. 
For  this  operation  the  instrument  represented  in  Fig.  123  is  preferable. 

It  consists  of  a  syringe,  with  a  glass  cylinder,  armed  with  a  double 
tip,  a  stop-cock,  and  two  adjustable  rubber  tubes — to  one  of  which  the 
needle  is  tightly  screwed.  When  about  to  be  used,  the  apparatus  should 
be  thoroughly  cleansed  in  1  to  20  carbolic-acid  solution,  and,  if  the  needle 
has  been  used  in  any  suspicious  matter,  it  should  be  heated  to  a  red  heat 
over  a  spirit-lamp,  and  cooled  off  in  1  to  20  carbolic-acid  solution.  The 
method  of  hyper-distention  of  an  abscess  with  an  antiseptic  fliiid  was  first 
prominently  brought  before  the  profession  by  Mr.  Callender.  The  cylinder 
should  be  filled  with  the  solution,  and  then,  while  holding  the  needle 
upward  so  that  any  air  which  may  have  entered  by  accident  will  escape 
first,  the  contents  should  be  foi'ced  out  until  only  about  one  third  of  the 


INFLAMMATIOK 


65 


cylinder  is  full.  By  this  manoeuvre  the  needle  and  tube  are  also  filled 
with  the  solution,  and  the  former  is  thrust  into  the  cavity  of  the  abscess 
and  held  steady  by  an  assistant.  The  operator  now  withdraws  the  piston 
slowly,  so  as  to  give  the  contents  sufficient  time  to  fill  the  tube,  which 


Fig.  123. — Combined  aspirator  and  irrigator. 

Otherwise  would  collapse  from  atmospheric  pressure.  As  soon  as  the 
cylinder  is  full  the  stop-cock  is  turned,  so  as  to  open  the  emptying  tube, 
which  motion  also  closes  the  one  communicating  with  the  abscess.  The 
contents  of  the  cylinder  shoiald  now  be  emptied,  and  the  evacuation  con- 
tinued until  the  pus  ceases  to  flow.  The  syringe  should  now  be  filled 
with  the  1  to  20  carbolic-acid  solution,  and  the  abscess  injected  until  its 
walls  are  over-distended,  when  the  fluid  is  withdrawn.  This  irrigation 
and  hyper-distention  may  be  repeated  several  times,  until  the  fluid  runs 
out  clear.  The  needle  is  then  removed,  a  plug  of  sublimate  gauze  placed 
over  the  puncture,  a  sublimate  gauze,  cotton,  and  protective  dressing 
over  this,  and  a  bandage  applied  over  all  tight  enough  to  compress  the 
opposite  walls  of  the  abscess  firmly  together. 

In  aspkation  of  an  abscess  it  is  usually  best  to  employ  the  large-sized 
5 


.66  A  TEXT-BOOK  ON  SURGERY. 

needle,  for  thick  pus  escapes  with  great  difficulty  through  the  small 
points.  It  is  not  infrequently  necessary,  even  when  a  large  needle  is 
used,  to  dilute  the  contents  of  the  sac  by  forcing  in  a  quantity  of  the 
liquid  befoi-e  it  can  be  brought  out  by  the  exhaustion.  Some  operators 
prefer  to  use  sublimate  (1  to  3,000)  rather  than  carbolic  acid.  When 
mercury  is  employed,  great  care  should  be  observed  in  thoroughly  evacu- 
ating the  sac  before  applying  the  dressing,  for  fear  of  poisoning  by  ab- 
sorption. One  operation  is  often  sufficient  to  effect  a  cure  by  this  method, 
and  when  carefully  done  to  the  exclusion  of  air,  and  with  the  thorough 
cleansing  of  the  abscess,  constitutional  disturbance  is  rare.  A  second, 
and  even  a  third,  injection  and  irrigation  may  be  tried.  Should  inflam- 
mation and  sepsis  follow,  free  incision  should  be  practiced  and  thorough 
drainage  established. 

Gold  Abscess. — Old  abscesses  which  produce  no  deformity  or  marked 
discomfort  to  the  patient  may  be  left  alone.  If  at  any  time  symptoms  of 
inflammation  and  sepsis  supervene,  prompt  and  free  incision  and  irriga- 
tion should  be  done,  and  drainage  maintained.  When,  by  reason  of  its 
situation,  it  becomes  advisable  to  operate  upon  a  non-inflamed  cold 
abscess,  aspiration  and  irrigation  should  be  performed  in  the  same  man- 
ner as  above  laid  down. 

Sepiiccemia  {a-7}-<{fi,<;,  jDutref action  ;  alfia,  blood),  or  blood-poison,  is 
caused  by  the  presence  in  the  blood  and  lymph-channels  of  certain  de- 
rivatives of  putrefactive  changes,  now  known  as  ptomaines,  and  it  is  held 
that  the  presence  of  micro-organisms  is  essential  to  the  production  of 
these  ptomaines,  and  their  entrance  into  the  blood  is  facilitated  by  the 
growth  and  migration  of  these  organisms. 

PycBmia  {t-vov,  pus)  is  a  severe  and  usually  fatal  form  of  blood-poison, 
characterized  by  the  formation  of  abscesses  in  various  parts  of  the  body, 
more  or  less  remote  from  the  center  of  suppuration  and  infection.  Since 
these  abscesses  are  caused  by  aggregations  of  micro-organisms,  carried  to 
the  heart  and  thence  disseminated,  they  are  called  metastatic  abscesses. 
Pysemia  is  therefore  properly  named  "  septicaemia  with  metastases." 

Sepdcsemia  following  inflammation  occurs  in  this  manner.  With  the 
emigration  of  leucocytes  and  effusion  of  serum  and  lymph,  the  micro- 
organisms of  suppuration  appear  in  the  inflamed  area,  and,  rapidly  mul- 
tiplying, establish  colonies  in  the  connective-tissue  spaces  (Fig.  119). 
The  tissues  immediately  adjacent  to  the  colonies  at  once  show  signs  of 
liquefaction,  and  the  quantity  of  seriim  and  lymph  is  notably  increased. 
The  various  foci  of  liquefaction  soon  coalesce  as  the  connective-tissue 
septa  disappear,  until  there  exists  a  single  collection  of  fluid,  the  liquor 
puris,  in  which  float  living  and  dead  leucocytes,  dead  embryonic  cells, 
shreds  of  broken-down  tissues,  and  shoals  of  micro-organisms  are  found. 

As  the  quantity  of  pus  is  augmented,  pressure  upon  the  surrounding 
structures  is  increased.  If  the  abscess  be  superficial  the  superjacent 
structures  are  protruded,  often  oedematous,  and  fluctuation  may  be  recog- 
nized. At  the  periphery  of  the  abscess  myriads  of  cocci  attack  the  bul- 
wark of  embryonic  tissue  {abscess-wall)  in  which  the  leucocytes  are 
crowded.     If  the  tissues  are  well  nourished,  and  thus  able  to  offer  th@ 


INFLAMMATION.  57 

proper  degree  of  resistance,  the  invasion  of  germs  is  arrested  and  the 
micro-organisms  perish  from  starvation,  or,  as  advanced  by  Metschnikoff, 
are  eaten  by  the  leucocytes  and  connective-tissue  corpuscles  (embryonic 
cells).  That  these  elements  act  as  phagocytes  (eating-cells)  requires  fur- 
ther demonstration  ;  that  they  are  active  agents  in  resisting  septic  inva- 
sion seems  now  demonstrated. 

Weigert  has  compared  the  cells  which  form  the  shell  around  a  suppu- 
rating area  to  an  army  resisting  invasion,  the  sej)sis-making  micro-organ- 
isms the  invading  host,  the  abscess  the  battle-field,  strewn  with  dead  and 
dying  of  both  combatants. 

Under  less  favorable  conditions  the  process  of  invasion  is  rapid,  and 
at  times  overwhelming.  Compression  of  the  circumjacent  tissues  causes 
occlusion  of  the  vessels  (thrombosis)  and  sloughing.  Cocci  invade  the 
lymph-channels  and  capillaries,  and  form  colonies  in  the  vein-clots. 
Liquefaction  occurring  in  the  thrombi,  particles  are  drawn  into  the  cir- 
culation, pass  to  the  heart,  and  are  distributed  into  the  lungs.  If  the 
septic  inflammation  is  in  the  area  of  the  portal  system  the  liver  is  usually 
first  afl'ected.  Wherever  the  septic  emboli  lodge,  secondary  abscesses 
occur,  germs  pass  through  into  the  capillaries  and  venules  of  the  lungs  (or 
in  the  liver,  the  lobular  and  sub-lobular  vessels),  and  general  metastases 
may  then  occur. 

It  is  exceedingly  probable  that  septicaemia  with  metastases  (pysemia) 
takes  place  from  infected  thrombi.  In  the  capillaries  the  colonies  of 
cocci  in  mass  can  not  be  transported.  They  do  invade  and  proliferate 
in  the  larger  lymph  vessels,  but  rapid  general  infection  is  here  retard- 
ed by  the  sieve-like  formation  of  the  glands.  Every  clinician  knows 
that  these  terrible  onslaughts  of  pyaemia  are,  as  a  rule,  sudden  and  over- 
whelming. 

Again,  in  Mr.  Bryant's  analysis  of  203  cases  of  pyaemia  at  Guy's  Hos- 
pital, the  lungs  were  involved  in  187  instances,  and  in  78  of  these,  infarc- 
tions occurred  in  no  other  organs.  Another  fact  not  without  weight  in 
support  of  this  argument  is  that,  in  suppuration  in  bone,  metastatic  sep- 
ticaemia is  more  apt  to  occur  than  in  the  softer  tissues.  Here  the  resist- 
ance to  expansion  is  so  great  that  infiltration  follows  the  Haversian  canals, 
coagulation  in  the  veins  (thrombosis)  takes  place,  invasions  of  micrococci 
occur,  and  septic  particles  pass  off  into  the  blood- current. 

As  above  stated,  the  life-history  of  these  organisms  is  short.  For 
dangerous  prolifei'ation  they  require  tissues  of  low  vitality  which  are 
breaking  down.  Resisted  properly,  they  perish  and  disappear.  In  cold 
abscesses  they  are  not  found. 

Treatment. — The  removal  of  the  source  of  infection  is  the  first  and 
chief  indication  in  treatment.  Incision,  drainage,  antiseptic  irrigation, 
are  all-imjjortant  factors  in  arresting  sepsis.  Reduction  of  temperature 
by  antifebrine,  gr.  v,  or  antipyrine,  gr.  x-xv,  every  hour  until  the  ther- 
mometer registers  101°  F.,  or  less,  is  as  important  as  stimulation  and 
careful  nourishment. 


CHAPTER  VI. 


A  WOUND  is  a  sudden  solntion  of  continuity  in  one  or  more  of  the 
tissues  of  the  body.  By  common  consent,  such  lesions  in  bone  and  carti- 
lage are  called  fractures. 

Wounds  are  operative  and  accidental,  and  may  be  classified  under 
four  leading  heads,  namely,  incised,  punctured,  lacerated,  and  contused. 
Any  breach  of  continuity  may  become  inoculated  with  a  virus,  or  venom  ;' 
it  is  then  a  poisoned  wound. 

Perforating  injuries,  caused  by  missiles  projected  from  guns,  demand 
especial  consideration  as  gunshot  wounds.  An  incised  wound  is  made 
by  a  clean  cut  with  a  sharp  instrument.  A  punctured  wound  is  caused 
by  a  narrow  instrument  which  penetrates  but  does  not  cut  laterally.  A 
lacerated  wound  is  made  by  a  dull  instrument  which  tears  the  tissues. 
A  contused  wound  is  one  in  which  the  tissues  are  more  bruised  than 
separated. 

The  changes  which  occur  in  the  tissues  during  the  infliction  of  a 
wound,  and  in  the  process  of  repair,  are  as  follows  :  Take,  as  an  example, 
an  incised  wound  across  the  anterior  aspect  of  the  middle  of  the  thigh. 

As  the  section  is  made,  the  capillaries,  arterioles,  and  venules  within 
the  field  of  irritation  instantly  contract,  and  immediately  thereafter 
become  dilated.  With  the  impingement  of  the  knife  the  tissues  retract, 
and  haemori'hage  occurs.  The  wound  fills  with  blood,  and,  if  no  large 
vessels  are  divided,  the  bleeding  may  cease  spontaneously  by  coagulation. 
The  chief  factor  in  rapid  coagulation  after  a  wound  is  the  presence,  in 
increased  quantity,  of  the  white  corpuscles,  which  increase,  as  before 
stated,  always  takes  place  within  the  irritated  zone.  Under  the  abnormal 
conditions  present,  coagulation  results  from  a  combination  of  the  para- 
globulin  of  the  leiicocytes  with  the  fibrinogen  of  the  j)lasma.  This  pro- 
cess not  only  occurs  in  the  blood  extravasated,  but  extends  along  the 
capillaries  back  from  the  edge  of  the  wound  to  the  nearest  anastomosis. 

Immediately  following  these  changes,  hypergemia,  redness,  swelling, 
heat,  and  pain  occur  in  the  edges  of  the  wound,  and  general  cell-prolifera- 
tion ensues,  as  described  in  the  preceding  chapter  on  Inflammation.  No 
repair  of  tissue  is  possible  without  this  inflammatory  process.  It  may 
be  mild  in  degree,  yet  it  must  of  necessity  exist.  A  reunion  of  atom  to 
atom,  capillary  to  capillary,  and  a  resumption  of  function  without  cell- 
proliferation,  can  not  occur. 


WOUNDS. 


69 


If  the  edges  of  the  wound  have  not  been  approximated,  the  space  left 
by  the  separation  of  the  tissues  begins  to  be  filled  in  a  few  days  with 
embryonic  or  granulation  tissue.  The  same  process  of  cell- proliferation 
occurs  in  the  walls  of  the  wound,  and  extends  as  far  back  as  the  zone  of 
inflammation.  The  most  essential  feature  of  the  earlier  process  of  repair 
is  the  new  formation  of  capillaries,  upon  which  the  integrity  of  the  more 
advanced  embryonic  cells  depends. 

It  has  been  stated  that  not  only  the  white  blood-cells,  but  all  the  stable 
cells  of  a  part  involved  in  an  inflammatory  process,  take  a  more  or  less  active 
part  in  the  general  proliferation  which  results  in  the  formation  of  the  com- 
mon embryonic  tissue.  The  cells  of  the  capillary-walls  are  among  the  first 
to  take  part  in  this  general  proliferation.  The  new  tissue  projects  in  minute 
tufts  or  granulation  buds  from  the  sides  and  bottom  of  the  wound.  In  this 
tissue  the  line  of  capillaries  is  advancing  ;  but  in  general  the  supply  of  nu- 
trition is  not  sufficient  to  maintain  the  vitality  of  the  more  advanced  or  su- 
perficial layers  of  cells,  and  these  may  i^erish  by  a  process  of  granular  degen- 
eration, or,  if  more  suddenly  deprived  of  the  necessary  quantity  of  blood, 
by  gangrene,  more  or  less  limited.  The  dead  tissue  floats  off  in  the  liquor 
puris,  provided  that  the  wound  is  infected  and  therefore  sup]3urating. 

The  new  formation  of  capillaries  in  the  embryonic  tissue  of  a  wound 
undergoing  repair  may  occur  in  any  of  the  following  ways :  1.  From 
the  nearest  capillary  arch  or  loop,  one  or  more  vascular  buds  are  pro- 
jected into  the  embryonic  mass,  as  shown  in  Fig.  124.     The  contact 


Fig.  124.— (After  Paget.) 


Fig.  125.— (After  Paget.) 


and  fusion  of  these  buds  form  new  loops,  which  process  continues  until, 
as  the  process  of  repair  nears  completion,  the  arches  from  one  side  meet 
and  fuse  with  those  advancing  from  the  other,  and  thus  establish  direct 
communication  across  the  track  of  the  wound.  2.  It  is  also  probable 
that  some  new  capillaries  are  formed  by  canalization  of  anastomosing 
cells,  a  process  analogous  to  the  formation  of  vascular  channels  in  the 
normal  embryonic  tissue,  especially  in  those  parts  -where  the  anastomos- 
ing plasmatic  ceUs  are  found.     3.  It  is  claimed  by  Kanvier  that  there  are 


70 


A  TEXT-BOOK   ON   SURGERY. 


developed  special  cells  for  vascular  new  formation,  wMch  lie  has  called 
"vessel-forming  cells."  4.  By  escape  of  leucocytes  from  the  capillaries, 
these  emigrant  cells  invade  the  new  tissue,  passing  between  the  cells  of 
the  enlbryonic  protoplasm.  In  their  wake  the  red  corjjuscles  and  liquor 
sanguinis  follow,  and,  by  pressure  upon  the  circumjacent  embryonic 
cells,  these  become  the  investing  membrane,  and  develop  into  the  capil- 
lary-wall (Fig.  125). 

With  the  establishment  of  a  capUlary  system  in  the  granulation  tissue 
of  a  wound  the  process  of  contraction  or  cicatiization  follows.  As  before 
stated,  some  of  the  embryonic  cells  undergo  fatty  degeneration  and  are 
absorbed,  or  die  and  are  washed  away  in  the  fluid  which  exudes  from  the 
surfaces  of  the  wound. 

Other  cells  develop  into  connective-tissue  elements,  and  form  the  con- 
tractins;  or  cicatricial  tissue  of  a  wound.     As  shown  in  Fig.  126,  the  first 


I'iG.  126.— (After  Paget.) 


change  is  in  the  nucleus,  which  is  more  readily  defined,  assumes  an 
oval  shape,  and  shows  within  it  one  or  more  nucleoli.  The  cells  become 
granular  and  more  fusiform,  finally  changing  into  a  series  of  wavy 
bundles  of  connective  tissue  (Paget).  This  process  of  attenuation  or 
contraction  is  of  course  accompanied  by  obliteration  of  many  of  the  new- 
formed  capillaries,  and  a  more  than  normal  bleaching  of  the  cicatrix,  as 
is  frequently  observed  in  scars  upon  the  integument,  where,  although  the 
epithelium  is  reproduced,  the  hair  and  sebaceous  fuUicles  are  not  found. 

In  the  process  of  repair  in  some  wounds,  especially  in  those  which  are 
slight  and  are  subcutaneous,  or  are  thoroughly  cleansed  and  their  walls 
brought  and  held  in  apposition  by  well-sustained  pressure,  reunion  may 
be  secured  without  pus-formation,  with  great  rapidity,  and  without  any 
constitutional  disturbance.  Cell-proliferation  under  such  favorable  con- 
ditions is  limited,  the  process  practically  physiological,  and,  while  many 
of  the  leucocytes  and  embryonic  cells  may  die,  the  mode  of  death  is  by 
granular  metamorphosis,  with  absorption  of  the  granular  matter.  Finally, 
all  wounds  heal  by  one  process  of  repair,  and  that  involves  iriflammaUon 
and  cell-proliferation.  It  may  differ  in  degiee  of  intensity  as  the  injury 
is  more  or  less  severe,  or  as  the  tissues  implicated  are  in  a  condition  to 
resist  disease. 

Treatment. — The  arrest  of  haemorrhage  is  the  first  indication.  Incised 
wounds  bleed  most  freely,  and  are  more  dangerous  in  this  particular  than 


i 


WOUNDS. 


71 


lacerated  and  contused  wounds.  In  one  the  vessels  are  smoothly  severed, 
in  the  other  the  ends  are  torn  in  shreds.  In  the  larger  vessels  retraction 
of  the  media  and  intima  occui's,  and  coagulation  is  more  readily  effected. 


Fig.  127. — (After  Esmarch.) 

Punctured  wounds  do  not  bleed  seriously 

unless  the  larger  vessels  are  opened.     On       j.,^.  las.I^etit's  spiral  tourniquet. 

account  of  the  extensive  lacerations  caused 

by  missUes  projected  fi-om  guns,  the  same  may  be  said  of  woimds  of  this 

class. 

Haemorrhage  from  an  artery  should  be  controlled  by  pressure  over 
the  main  trunk,  between  the  wound  and  the  heart,  until  the  ends  of  the 


Fig.  129. — ^Petit's  tourniquet  applied  in  the  brachial  and  femoral  arteries.    (After  Esmarch.) 

vessel  can  be  secured  with  the  catgut  ligature.     Venous  hsemorrhage 
requires  the  elevation  of  a  part  (when  an  extremity  is  involved),  and 


72 


A  TEXT-BOOK   ON  SURGERY. 


pressure  upon  the  distal  side  of  the  wound  until  the  ligature  can  be 
applied  to  the  bleeding  point.  While  not  so  essential,  it  is  best  to  tie 
both  ends  of  a  divided  vein.     Direct  pressure  in  the  seat  of  a  wound  win 


Fig.  130.— (After  Esmarch.)        Fig.  :31.— (After  Esmarch.)  Fig.  132.— (After  Esmaroh.) 


arrest  ordinary  haemorrhage.  When  the  bleeding  is  from  an  extremity, 
an  emergency  tourniquet  may  be  made  by  tying  a  bridle-rein,  rope,  piece 
of  cloth  (as  the  leg  of  a  pair  of  trousers,  or  coat-sleeve),  or  any  other  sub- 
stance, around  the  part  above  the  wound,  and  twisting  this  by  means  of 


WOUNDS. 


73 


a  stick,  bayonet,  sword,  or  gun-barrel,  properly  inserted  (Fig.  127).  The 
efficiency  of  this  method  of  compression  is  increased  by  placing  a  pad 
over  the  main  artery.  Compression  of  an  artery  with  the  thumb  or  finger, 
or  a  padded  key  or  stick,  will  be  of  service  in  any  emergency  where  a 
tourniquet  can  not  be  had. 

The  tourniquet  of  Petit  (Fig.  128)  is  one  of  the  older  and  move  useful 
instruments.     Its  application  is  illustrated  in  Fig.  129  {a  and  h). 

EsmarcKs  elastic  bandage,  or  tourniquet,  is  the  most  generally  useful 
of  all  the  constricting  haemostatic  apparatus.  It  may  be  thrown  around 
a  part,  between  the  bleeding  point  and  the  heart,  or  it  may  be  applied 
from  the  tip  of  the  extremity,  and  over  and  on  the  cardiac  side  of  the 

wound,  and  here  se- 
cured, while  the  por- 
tion beyond  is  removed. 
In  this  way  the  limb 
is  rendered  bloodless 
(Figs.  130,  131,  132). 
This  excellent  appara- 
tus may  be  employed 
in  compression  of  the 
iliacs  (Fig.  133)  and  the 
abdominal  aorta  (Fig. 
134). 

When  the  immediate 
flow  of  blood  is  arrested 
by  any  of  the  foregoing 
methods,  the  perma- 
nent arrest  of  hsemor- 
rhage  must  be  secured 
by  the  ligature  at  the 
divided  point.  For 
this  purpose  the  artery- 
forceps  and  the  catgut- 
ligature,  ali-eady  de- 
scribed, will  be  found 
by  far  the  most  pref- 
erable. Torsion  is  not 
Fia.  134.— (After  Esmaroh.)  as    Safe   as    the    liga- 

ture, and  should  not  be 
employed  when  catgut  can  be  had.  The  actual  cautery,  packing  with 
styptic  cotton.,  and  acupressure  are  methods  never  to  be  employed  when 
anything  else  can  be  done.  If  a  wound  must  be  packed,  and  if  sublimate 
gauze  can  not  be  had  for  this  purpose,  use  clean  linen  or  cotton  cloth. 
Gold  water,  or  water  Tieated  to  about  120°  to  130°  F.,  will  prove  of  value 
as  a  haemostatic.  Elevation  of  a  part,  and  well-adjusted  compression  by 
dressing  and  bandage,  will  always  be  made  available  by  the  surgeon  of 
experience.  AVhile  the  ligatures  are  being  applied,  and,  in  fact,  before 
this  time,  the  entire  surface  of  the  wound  should  be  irrigated  with  1  to 


Fig.  133.— (After  Esmareh.) 


74  A  TEXT-BOOK  ON  SURGERY. 

3,000  sublimate  solution,  and  thoroughly  cleansed  of  all  clots  or  foreign 
matter.  Next  to  sublimate,  1  to  20  carbolic  acid  is  preferable,  and,  when 
neither  of  these  solutions  can  be  obtained,  the  purest  water  should  be 
freely  used,  and  this  should  first  be  boiled  and  allowed  to  cool  to  about 
110°  F.  It  rarely  occurs  in  an  extensive  wound  that  aU  haemorrhage 
can  be  stopped,  for  a  general  oozing  takes  jDlace  fi'om  capillaries  too 
numerous  to  tie.  Haemorrhage  of  this  character  may  be  arrested  by 
elevation  of  the  part,  or  pressure  either  by  approximation  of  the  walls 
of  the  wound,  by  packing,  or  by  general  compression  of  the  part 
with  a  bandage.  If  the  edges  ai-e  to  be  closed  with  sutures,  the  pack- 
ing must  be  temporary.  It  is  most  successfully  practiced  by  crowding 
the  wound  full  of  sponges,  which  have  just  been  taken  out  of  a  basin 
of  hot  sublimate,  and  well  pressed  between  the  fingers.  A  hot  sub- 
limate towel  is  laid  over  these,  and  firm  pressiire  made  for  about  five 
or  ten  minutes  with  the  hand  or  a  roller.  Genei-al  comioression  of  a 
limb  is  only  well  adapted  to  a  wound  which  has  been  made  or  cleansed 
under  Esmarch's  bandage.  After  the  important  vessels  are  secured, 
the  wound  is  closed,  drainage-tubes  inserted,  a  sublimate  gauze  dress- 
ing applied,  and  over  this  cotton  wadding  about  one  inch  in  thickness. 
A  layer  of  protective  is  placed  over  this,  and  the  necessary  pressure 
employed  by  means  of  an  ordinary  roller.  It  is  impossible  to  convey 
an  idea  of  the  amount  of  compression  to  be  used  in  applying  the  roUer. 
It  should  be  tightly  drawn,  and  as  long  as  the  tips  of  the  toes  or  fingers 
are  left  out  for  constant  inspection,  so  that  any  arrest  of  the  circulation 
may  be  immediately  discovered,  no  danger  is  incurred. 

In  closing  a  wound  by  sutures,  the  points  of  chief  importance  are  to 
secure  drainage  and  to  bring  all  parts  of  the  opposing  surfaces  together 
with  equally  distributed  i>ressure.  A  Avound  which  gapes  at  the  top  or 
bottom,  or  in  the  middle,  is  not  well  dressed.  As  for  drainage,  the 
material  for  which  has  been  already  discussed,  the  cardinal  law  is  that, 
in  the  position  in  which  the  part  must  rest  after  the  operation,  the  fluids 
should  readily  gravitate  from  the  deepest  portion  of  the  wound  out  into 
the  dressings.  Before  approximating  wounded  surfaces,  if  lacerations 
have  occurred,  the  shreds  of  tissue,  which  will  probably  slough,  should 
be  trimmed  off  with  the  scissors,  and  the  walls  rendered  as  fresh  and 
smooth  as  circumstances  will  admit.  It  is  always  desirable  that  the  edges 
of  the  wound  in  the  skin  should  be  perfectly  smooth,  so  that  a  close 
adaptation  may  be  secured  and  an  ugly  scar  avoided.  This  is  especially 
essential  upon  the  face,  neck,  and  hands. 

In  closing  shallow  wounds,  or  those  of  not  more  than  one  or  two 
inches  in  dei)th,  it  will  usually  suflBce  to  pass  the  needle  from  one  fourth 
to  one  half  of  an  inch  from  the  edge,  and  down  into  the  tissues,  so  that 
it  will  emerge  well  domi  toward  the  bottom  of  the  wound.  It  should 
now  be  entered  in  the  opposite  wall  of  the  wound  at  the  same  depth,  and 
brought  up  through  the  integument  at  a  point  corresponding  to  that 
where  the  needle  originally  entered.  AVhen  a  suture  inserted  in  this 
manner  is  tied,  it  is  readily  seen  that  in  approximating  the  wounded 
surfaces  the  pressure  is  equally  distributed  at  the  surface  and  in  the 


WOUNDS. 


75 


deeper  portions.  When  imjDortant  vessels  and  nerves  are  in  relation  to 
the  walls  of  the  divided  tissues,  great  care  should  be  taken  to  avoid  trans- 
fixing these.  In  deeper  wounds,  an  initial  row  of  catgut  sutures  may  be 
used  by  passing  the  curved  needle  into  the  tissues  of  the  two  sides 
well  below  the  integument,  and  tying  these  before  the  superficial  threads 
are  inserted.  These  deep  sutures  are  rarely  necessary,  however,  since 
the  surfaces  may  be  held  in  apposition  by  the  bandaging.  Of  the  various 
forms  of  suture,  that  known  as  the  interrupted  is  the  most  useful  and 
satisfactory.  As  shown  in  Fig.  135,  the  stitches  may  all  be  on  the  same 
plane,  or  there  may  be  a  wide  and  deep,  and  an  intermediate  and  more 
superficial  row,  as  shown  in  Fig.  136.  Whatever  form  is  employed,  care 
should  be  taken  that  as  the  knot  is  tightened  the  edges  of  both  sides 
should  be  exactly  on  the  same  level.  In  order  to  effect  this,  it  is  often 
necessary  to  lift  one  side  with  a  dkector  or  hook,  or  depress  the  other  to 
the  proper  level  with  a  dull  instrument.  No  fat  or  shred  of  tissue  should 
be  allowed  to  bulge  up  between  the  edges,  but  should  be  pushed  out  of 


K  \ 


sight  with  a  probe  or  forceps  while  the  suture  is  tied.  In  order  to  prevent 
slipping,  the  first  knot  should  be  the  double  friction-loop  (see  page  51), 
which  is  the  only  one  that  will  hold  its  grip  while  the  second  single  loop 
is  being  tied  to  secure  the  knot.  It  is  best  to  keep  the  knots  away  from 
the  line  of  the  approximated  edges.  In  tightening  the  sutures  the  efl'ort 
should  be  made  to  bring  the  lips  of  the  wound  together  nicely  without 
sufficient  tension  to  pucker  or  v\Tinkle  the  skin,  or  to  cause  it  to  be  in- 
folded or  to  be  turned  white  from  too  much  pressure.  When  expedition 
rather  than  nice  adjustment  is  desired,  the  continuous  suture  (Fig.  137) 
may  be  practiced.  The  needle  is  always  passed  at  a  right  angle  to  the 
axis  of  the  wound,  although  that  part  of  the  suture  which  is  visible 
crosses  it  obliquely.  The  mattress  suture,  shown  in  Fig.  138,  and  the 
quitl  suture,  at  Fig.  139,  are  practically  obsolete.  They  possess  no  ad- 
vantages which  do  not  belong  to  the  interrupted  or  continuous  methods. 
The  silver-wire  suture  is  always  interrupted.  The  application  is  well 
shown  in  Fig.  140.     After  the  proper  apposition  is  secured  by  the  first 


76  A  TEXT-BOOK   ON   SURGERY. 

twist,  made  with  the  fingers  down  at  the  level  of  the  skin,  the  ends 
shonld  be  clasped  in  an  artery-forceps  and  turned  eight  or  ten  times. 


1  ij ' 

i^^  Ill- 
Ill 

I 
ill 


The  pin-suture  is  still  pojpnlar  with  a  number  of  surgeons.  Silver 
pins,  or  the  ordinary  iron  pin  of  commerce,  may  be  employed,  and  the 
adjustment  of  the  opposing  surfaces  made  more  complete  by  throwing  a 
silk  or  catgut  interrupted  loop,  or  figure-of-8,  around  the  ends  of  the 
pin  (Fig.  141),  or  a  continuous  figure-of-8  applied,  as  shown  in  Figs.  142 
and  143. 


^^^ 


_  ,^1 


When  it  becomes  necessary  to  close  a  three-cornered  wound,  a  cross- 
suture  (Fig.  144)  may  be  utilized,  or  the  double-needled  suture  (Fig.  145) 
may  be  substituted. 

Superficial  lesions  may  be  closed  by  adhesive  strips,  although  this 
method  is  less  exact  and  less  cleanly  than  the  sutures.  The  strips  should 
be  cut  narrow,  and  it  is  always  necessary  to  have  the  parts  to  which  they 
are  to  be  applied  dry  and  warm,  else  the  plaster  will  not  stick.  The 
adhesive  strips  hold  readily  when  warmed,  as  they  are  applied,  or  when 
moistened  with  turpentine.     The  strips  may  be  dovetailed,  or,  while  the 


WOUNDS.  77 

edges  of  the  wound  are  held  in  apposition,  laid  directly  across  the  line  of 
approximation. 

Another  method,  less  frequently  employed,  yet  useful  at  times,  is  to 
take  a  piece  of  plaster  and  fasten  it  to  the  skin  parallel  with  the  edge  of 
the  wound.  A  half-inch  of  this  margin  is  folded  back,  and  to  this  hooks 
are  attached  and  elastic  threads  drawn  directly  across  or  in  figure-of-8 
fashion,  graduating  the  pressure  necessary  to  a  proj)er  apposition. 

The  needles  for  carrying  sutures  should  be  of  various  patterns,  and  of 
all  sizes,  for  different  purposes.  Some  are  straight  and  round,  others 
are  lance-shaped  ;  some  should  be  crescentic,  others  straight  for  the  half 
or  two  thirds  of  the  shaft  nearest  the  eye.  and  curved  toward  the  point. 
In  general  a  needle  should  not  cut  laterally  while  it  is  being  introduced, 
since  the  lance-pointed  variety  not  infrequently  causes  annoying  hsemor- 
rhage  by  division  of  vessels,  which  the  round,  or  smooth  needles  would 
push  to  one  side. 

A  good  needle-Jiolder  is  one  of  the  most  useful  instruments  of  the 
operator's  outfit.  It  should  have  a  handle  large  enough  to  be  well 
grasped  without  cramping  the  fingers,  and  strong  enough  to  stand  any 
required  force.  The  instrument  shown  in  Fig.  88  will  be  found  to  be 
very  satisfactory.  It  is  readily  locked  and  unlocked,  and  is  to  be  com- 
mended for  having  at  the  tip  a  cop)per  grip  for  curved  as  well  as  straight 
needles,  and  an  attachment  for  the  Hagedorn  or  flat  needle. 

After  the  wound  is  closed,  and  the  final  irrigation  made,  the  antiseptic 
dressing  heretofore  described  should  be  applied. 

When  Jicemorrhage  has  been  so  profuse  that  death  from  syncope  is 
imminent,  the  head  should  be  lowered  so  that  gravity  will  aid  the  flow  of 
blood  to  the  brain  in  the  hope  of  maintaining  its  functions.  The  admin- 
istration of  whisky  by  the  mouth  or  hypodermically  is  indicated.  If  the 
bleeding  is  occurring  internally,  an  effort  must  be  made  to  confine  as 
much  blood  as  jDossible  in  the  extremities,  and  to  hold  it  there  until,  the 
pressure  at  the  bleeding-point  being  relieved,  stasis,  coagulation,  and 
arrest  occur.  This  method  I  have  practiced  in  several  serious  cases,  and 
have  seen  its  efficacy  demonstrated.  Both  arms  near  the  shoulder,  and 
both  thighs  six  inches  below  Poupart's  ligament,  are  constricted  by  towels, 
cloths,  or  bandages  of  muslin  or  rubber,  which  are  tightened  just  enough 
to  retard  or  arrest  the  return  venous  circulation,  and  not  to  interfere 
with  the  outgoing  current  in  the  arteries.  In  this  way  several  pounds 
of  blood  may  be  held  away  from  the  bleeding-point  and  turned  into  the 
circulation  when  the  ha?morrhage  ceases.  Care  mast  be  taken  not  to 
produce  fatal  syncope  by  keeping  too  much  from  the  braiu,  and  also  not 
to  return  too  much  of  the  pent-up  volume  into  the  circulation  at  once. 
Fluid  extract  of  ergot,  tU  xxx,  hypodermically,  every  fifteen  minutes  until 
3  J  to  3  ij  doses  are  given,  is  one  of  the  best  medical  hgemostatics.  If, 
despite  these  efforts,  fatal  syncope  is  imminent,  transfusion  is  imperative. 

The  proper  solution  is  :  Sodium  chloride,  gr.  xciij ;  liquor  sodte,  tii  xx  ; 
aquse,  O  ij.  From  8  to  40  ounces  of  this  mixture  at  the  temperature  of 
the  blood  have  been  successfully  introduced.  This  simple  and  efficient 
method  of  transfusion  may  be  effected  through  a  vein  or  an  artery. 


78 


A  TEXT-BOOK   ON   SURGERY. 


Bischoif  injected  §  xl  into  the  radial  artery  of  a  woman,  the  operation 
lasting  one  hour,  and  the  patient  recovered.  Szamann  and  many  others 
have  successfully  employed  this  method  by  injecting  into  a  vein.  In  a 
case  in  the  practice  of  my  colleague.  Prof.  Munde,  I  introduced  5  viij 
through  the  median-cephalic  vein  within  ten  minutes.  This  quantity  was 
twice  repeated  in  twelve  hours.  The  ap- 
paratus I  employed  is  shown  in  Fig.  146. 
It  consists  of  a  funnel,  to  the  tip  of  which 
a  rubber  tube  is  attached.  To  the  end  of 
the  tube  is  a  canula  for  introduction  into 
the  vein.  Open  the  vein,  or  utilize  one  al- 
ready opened,  in  the  wound  if  this  is  pos- 
sible. Warm  the  solution  to  about  100° 
F.,  fill  the  apparatus,  and  allow  a  small 
quantity  to  escape  through  the  pipette  in 
order  to  be  sure  that  no  air  is  introduced. 
If  then  the  stop-cock  is  turned,  or  the  rub- 
ber tube  compressed,  the  canula  will  be 
held  full  of  fluid.  After  it  is  carried  into 
the  vein  it  should  be  held  in  place  by  a 
ligature  tied  around  toe  vessel,  just  behind 
the  expansion  at  the  nozzle.  If  the  stop- 
cock is  now  turned  on,  the  fluid  gravitates 
into  the  vein.  The  quantity  and  rapidity 
of  the  injection  may  be  regulated  by  press- 
ure upon  the  tiibe,  or  by  elevation  of  the 
funnel.  The  introduction  should  be  slow- 
ly and  gradually  accomplished.  Any  ordi- 
nary syringe,  if  thoroughly  cleansed,  may 
be  employed.  Care  should  always  be 
taken  to  prevent  the  introduction  of  air. 
The  aspirator  heretofore  figured  is  an  ex- 
cellent instrument  for  transfusion  into  a 
vein  or  artery. 

The  older  methods  of  transfusion  with 
defibrinated  blood,  or  direct  transmission 

from  the  arm  of  the  giver  to  that  of  the  patient,  are  now  completely 
superseded  by  the  saline  solution.  Successful  transfusion  of  simple 
water  at  the  temperature  of  the  blood  has  also  been  accomplished. 

Poisoned  Wounds. — When  a  venom  or  virus  is  introduced  into  the 
tissues  through  a  solution  of  continuity,  it  is  called  a  poisoned  wound. 

Snalce-Bite. — The  venom  of  certain  reptiles  carried  into  the  circulation 
through  a  wound  produces  alarming  and,  at  times,  fatal  results.  The 
intensity  of  its  action  is  in  proportion  to  the  quality  and  quantity  of  the 
poison  absorbed,  as  well  as  to  the  rapidity  of  its  introduction.  Thus,  the 
venom  of  the  cobra  and  rattlesnake  is  more  fatal  than  that  of  many 
other  forms.  Again,  the  venom  lodged  in  the  skin  and  subcutaneous 
areolar  tissues,  and  absorbed  by  the  lymph-vessels  and  capillaries,  is  far 


womsTDs.  79 

less  potent  for  evil  than  that  which  is  injected  into  a  vein,  overwhelming 
the  heart  and  sensorium  by  its  rapid  introduction. 

The  order  of  toxicity  in  serpent-venom,  so  far  as  known  at  this  date, 
is  as  follows  :  1.  Cobra  {Nala  tripudians),  a  native  of  India  ;  rattlesnake 
(Crotalus  durissus  and  C.  adamanteus),  of  southern  North  America- 
BotTiro'p  jararacassa  and  B.  jararaca,  closely  allied,  according  to  Dr. 
Robert  Fletcher,*  in  the  intensity  of  its  venom  to  its  congener,  the  North 
American  rattlesnake  ;  American  copper-head  {Trigonocephalus  oontor- 
trix) ;  the  American  moccasin  {Toxicophis  atrapiscus  and  T . piscinorus) ; 
the  spreading  adder,  of  the  order  Vipera  hems. 

The  venom  of  snakes  is  excreted  by  a  gland  situated  near  the  eye. 
In  the  act  of  striking  or  biting  it  is  forced  by  a  compressor  muscle  along 
a  channel,  or  groove,  in  the  fang.  In  the  quiescent  state  the  fangs  (one 
on  either  side)  are  folded  backward,  and  are  buried  in  grooves  in  the 
mucous  membrane  of  the  roof  of  the  mouth.  When  ready  for  use,  they 
are  drawn  forward  by  erector  muscles.  Rattlesnake-venom,  according 
to  Dr.  S.  Weil-  Mitchell, f  has  a  specific  gravity  of  1-044,  and  an  invariably 
acid  reaction.  Its  color  is  from  a  greenish  to  a  straw  tint.  Conjointly 
with  Dr.  Edward  T.  Reichert,:}:  he  has  isolated  three  proteids— namely, 
venom-peptone,  venom-globulin,  and  venom-albumen.  Venom-globulin 
is  intensely  toxic,  producing  raj)id  extravasations  of  blood  ;  venom-pep- 
tone is  less  poisonous,  but  produces,  when  injected  into  the  breasts  of 
pigeons,  intense  sloughing.  The  albumen-venom  is  not  yet  fully  under- 
stood. Bromine,  iodine,  sodium,  and  potassium  hydrate  and  potassium 
permanganate  destroy  chemically  the  toxic  property  of  the  venom  of  the 
rattlesnake,  copper-head,  and  moccasin.  Serpent  -  venom  produces  no 
poisonous  effect  in  the  tissues  of  the  reptUe  which  produces  it,  or  in  the 
tissues  of  any  venom-producing  reptile. 

As  just  stated,  the  symptoms  resulting  from  snake -bite  in  man 
vary  with  the  toxicity  of  the  venom,  the  amount  introduced,  and  with 
the  rapidity  with  which  it  is  carried  into  the  circulation.  A  keeper  in 
the  London  Zoological  Gardens  was  bitten  on  the  nose  by  a  cobra,  and 
died  in  a  little  more  than  one  hour.*  Dr.  Wainwright,  of  New  York 
city,  died  within  six  hours  after  being  bitten  by  a  rattlesnake.  ||  Dr.  G. 
A.  Kunkler  ^  reports  the  case  of  a  boy  six  years  old,  who  died  during  a 
convulsion  on  the  fourth  day,  after  being  bitten  on  the  foot  by  a  copper- 
head. The  venom  is  seemingly  as  potent  in  cold  as  in  warm  weather. 
Dr.  E.  P.  King  ^  treated  a  patient  in  whom  well-marked  toxic  symptoms 
were  developed  after  being  bitten  by  a  copper-head  which,  although 
torpid,  had  recovered  its  activity  under  the  influence  of  heat.    When  the 

*  "American  Journal  of  the  Medical  Sciences,"  July,  1883. 
t  Smithsonian  Contributions,  1860.     "New^  York  Medical  Journal,"  1868. 
t  "Philadelphia  Medical  News,"'  1883. 
"^  Bryant's  "Surgery." 
II  Hamilton's  "  Surgery." 

'^  "Cincinnati  Lancet  and  Observer,"  1859.     "American  Journal  of  the  Medical  Sciences," 
April,  1883. 

^  "American  Journal  of  the  Medical  Sciences,"  April,  1884,  p.  428. 


80  A  TEXT-BOOK   ON   SURGERY. 

clothing  intervenes,  the  venom  is  likely  to  be  in  part  arrested,  and  the 
effect  less  severe. 

Pain  of  a  sharp  or  stinging  character  is  nsnally  felt  in  the  wound. 
Fright  or  shock  may  mask  this  symptom.  Swelling  rapidly  ensues,  and 
in  rattlesnake-bite  ecchymosis  is  not  uncommon.  The  swelling  extends 
in  all  directions,  but  is  most  marked  in  the  line  of  the  lymphatics  toward 
the  center.  Headache,  fever,  rigors,  irregular  breathing,  and  a  low,  fee- 
ble pulse,  with  nausea,  may  be  present.  Adenitis,  abscess,  or  sloughing 
usually  occur.  If  death  does  not  ensue,  the  case  may  terminate  favor- 
ably in  two  or  three  days,  or  last  for  weeks  and  months.  ' 

Treatment. — The  immediate  indication  is  the  removal  of  the  venom. 
Labial  suction  is  an  efficient  method,  and  may  be  safely  practiced,  pro- 
vided that  there  is  no  abrasion  on  the  lips  or  contiguous  mucous  sur- 
faces. Inoculation  is  more  dangerous  about  the  mouth  and  neck  than 
elsewhere,  since  the  great  swelling  may  close  the  trachea  or  larynx. 
Next  in  order  of  readiness  is  free  and  immediate  excision  of  the  tissues 
within  a  radius  of  half  or  three  fourths  of  an  inch  from  the  puncture, 
or  free  incisions  may  be  made  so  that  the  flow  of  blood  may  wash  the 
venom  out. 

Permanganate  of  potassium  is  probably  the  best  chemical,  and  whisky 
(or  alcohol  in  some  other  form)  the  best  physiological  antidote.  Dr.  de 
Lacerda,*  of  Brazil,  recommends  the  immediate  injection  in  and  around 
the  wound  of  a  1-per-cent  (gr.  v  to  §  j)  solution  of  the  permanganate  in 
water,  and  also  an  intra-venous  injection  if  the  venom  has  had  time  to 
enter  the  circulation.  Dr.  Robert  Fletcher  f  states  that  Richards,  of  Cal- 
cutta, after  repeating  Lacerda's  experiments,  recommends  a  5-per-cent 
solution  in  cobra-poison  ;  3  j  to  3  iv  of  a  solution,  varying  from  gr.  v  to 
gr.  X  to  water  §  j,  would  be  about  the  safest  treatment  for  rattlesnake- 
venom  ;  and  the  weaker  solutions  for  copper-head  and  moccasin  bites.  It 
must  not  be  foi'gotten  that  this  salt  is  toxic  in  overdoses.  Vulpian  pro- 
duced death  in  a  small  dog  with  an  injection  of  gr.  vij.  Whisky,  or  any 
form  of  alcohoil,  is  a  favorite  cardiac  stimulant,  and  may  be  taken  in 
adults  in  large  quantities  without  intoxication.  Care  must  be  taken  in 
administering  alcohol  to  children,  since  it  has  occasionally  proved  fatal. 

When  great  swelling  occurs,  and  gangrene  is  threatened  on  account 
of  tension,  free  incisions  or  punctures  should  be  made. 

The  venom  of  some  of  the  lizard  family,  as  the  Gila  monster;};  (Helo- 
derma  suspectum)  and  the  toad  *  {Bufo  mdgaris),  also  possesses  toxic 
properties.  The  treatment  should  be  about  the  same  as  given  above  for 
serpent-venom,  though  not  quite  so  energetic. 

Venom  introduced  with  the  sting  of  the  scorpion  not  infrequently 
causes  death  in  the  Orient,  although  the  sting  of  the  North  American 
scorpion  is  not  dangerous.     I  have  failed  to  hear  of  a  death  from  this 

*  "  Gazette  des  liopitaux,"  1881,  pp.  597  and  891.    Also,  a  valuable  paper  by  Dr.  H.  C.  Yar- 
row, "American  Journal  of  the  Medical  Sciences,"  April,  1884. 
t  "American  Journal  of  the  Medical  Sciences,"  July,  1888. 
X  Mitchell  and  Reichert,  "  Medical  News,"  Philadelphia,  1883. 
«  "  Gazette  des  h6pitaux,"  1881,  p.  598. 


WOUNDS.  8X 

accident,  altliougli  I  have  made  personal  inquiry  from  numerous  prac- 
titioners in  the  South  and  West,  who  have  had  much  experience  with 
these  cases.  In  a  personal  experience,  in  which  I  was  stung  by  a  scor- 
pion in  the  palm  of  the  hand,  no  unpleasant  symptom  followed.  As  soon 
as  the  insect  was  brushed  off,  the  venom  was  removed  by  sucking  the 
wound,  and  by  expression. 

The  venom  of  the  tarantula,  and  other  spiders,  is  occasionally  fatal. 
In  a  private  communication.  Dr.  Thomas  A.  Pope,  of  Texas,  who  has  seen 
many  cases  of  tarantula-bite,  reports  one  fatal  case.  Death  did  not  ensue, 
however,  from  the  changes  induced  in  the  blood  by  the  venom,  but  from 
asphyxia  due  to  closure  of  the  larynx  and  trachea  from  great  swelling, 
the  man  having  been  bitten  in  the  neck. 

The  swelling  is  usually  severe,  and  an  erythematous  rash  occurs  about 
the  second  day.  This  may  occupy  one  half  or  all  of  the  body.  Slough- 
ing at  the  wound  almost  always  occurs. 

The  stings  of  bees,  wasps,  liornets,  etc.,  possess  a  venom  which,  while 
rarely  fatal,  is  painful  and  annoying.  The  application  of  an  alkaline 
solution  will,  if  immediately  used,  neutralize  the  pain  and  the  tendency 
to  swelling.  Clay  moistened  into  a  paste  with  the  saliva  is  an  effective 
remedy  used  by  the  negroes  in  the  Southern  States.  The  sting  should  be 
removed  if  it  has  remained  in  the  wound.  In  the  case  of  a  negro  child, 
three  years  old,  who  had  just  a  minute  or  two  before  been  stung  by  about 
forty  bees,  no  serious  symptom  ensued.  The  treatment  followed  was 
brushing  the  insects  off  with  a  sheet,  and  thoroughly  sponging  the  entire 
body  with  a  solution  of  a  teacupful  of  ordinary  saleratus  in  two  quarts  of 
water. 

The  venom  of  the  centipede  scarcely  deserves  mention.  I  am  told  by 
physicians  isracticing  in  the  sections  infested  by  these  Myriapoda  that 
their  toxic  power  is  miich  exaggerated.  The  slight  effects  which  follow 
their  foot-marks  and  the  bite  of  the  tarantula  should  be  treated  by  per- 
manganate of  potassium  locally  and  stimulants  internally. 

Hydropliohia. — The  bite  of  certain  animals,  as  the  wolf,  dog,  fox,  and 
cat,  is  at  times  followed  by  alarming,  and  often  fatal  sjnnptoms,  due  to 
the  absorption  of  a  specilic  virus.  It  was  formerly  thought  that  the 
saliva  alone  was  the  menstruum  for  this  poison,  but  Pasteur  *  has  I'ecently 
claimed  that  he  has  produced  rabies  in  animals  inoculated  with  the 
cephalo-rachidian  fluid,  and  the  nerve-matter  of  the  medulla  oblongata 
of  other  animals  suffering  from  this  disease.  He  also  claims  that  by 
successive  cultures  of  the  specific  germ  of  this  disease,  and  inoculations 
with  the  cultures,  immunity  fi'om  rabies  may  be  secured.  While  any 
statement  from  this  great  scientist  is  entitled  to  credence — and  while  the 
report  of  the  commission  appointed  by  the  French  Government  fuUy 
proves  the  success  of  Pasteur's  method  in  animals — it  is  not  yet  fuUy 
determined  that  vaccination  will  give  immunity  to  man,  nor  prevent  the 
development  of  rabies  after  inoculation. 

Hydrophobia  may  follow  the  bite  of  an  aidmal  seemingly  in  jjerfect 

*  "  Gazette  des  hopitaux,"  1881,  p.  502.     Hid.,  1884,  p.  733. 


82  A  TEXT-BOOK   ON   SUKGERY. 

health,  as  well  as  from  one  noticeably  affected  with  rabies.  In  man  and" 
other  animals  it  may  occur  at  any  season  of  the  year,  and  in  all  climes. 
The  wound  inflicted  always  heals  slowly,  even  without  regard  to  the 
inoculation  of  the  specific  virus,  for,  in  addition  to  being  contused  and 
lacerated,  it  is  infected  by  contact  with  the  saliva,  which  even  in  man 
Sternberg  *  has  shown  will  produce  fatal  sepsis  when  injected  into  the 
tissues  of  animals. 

The  period  of  incubation  in  rabies  in  man  varies  from  five  days  to  as 
many  months,  and  in  exceptional  instances  to  as  long  as  one  or  two 
years.  The  symptoms  of  its  approach  are  often  vague.  Pain  in  the 
track  of  the  sensory  nerves  leading  from  the  wound,  and  in  and  about 
the  wound  or  scar,  is  given  as  among  the  earlier  indications.  Irregular 
heart-action  occui-s,  together  with  respiratory  disturbance  of  a  convulsive 
character.  The  face  expi'esses  a  sense  of  actual  suffering,  or  of  anxiety 
in  the  anticipation  of  impending  disaster.  Nausea,  increased  flow  of 
saliva,  and  vomiting  occur,  and  often  are  followed  by  general  or  partial 
convulsive  movements!  Death  ensues  usually  between  the  second  and  fifth 
day.  Prof.  Flint  f  is  of  the  ox)inion  that  no  well-authenticated  case  has 
ended  in  recovery.  In  three  out  of  seven  cases  examined  by  Southam  X 
sugar  was  present  in  the  urine,  which  fact  indicates  irritation  of  the 
medulla,  and  is  corroborative  of  Pasteur' s  *  statement  that  the  gray  mat- 
ter of  the  brain  and  cord,  and  especially  the  medulla  oblongata,  is  affected 
by  the  poison  (microbes)  of  rabies. 

Treatment. — Preventive  measures  are  of  first  importance.  If  Pasteur 
is  correct  in  his  deductions — and  there  is  little  doubt  of  his  success  with 
animals — enforced  inoculation  (vaccination)  of  all  dogs  and  cats  should  be 
practiced.  The  wound  inflicted  by  any  animal,  and  especially  one  either 
suspected  or  known  to  be  suffering  from  rabies,  should  be  immediately 
and  freely  excised,  or  the  parts  in  and  around  the  wound  destroyed 
by  the  actual  cautery,  or  by  a  penetrating  escharotic.  When  situated 
upon  a  part  of  the  body  which  can  be  brought  in  contact  with  the  mouth, 
the  blood,  and  with  it  the  virus,  may  be  removed  by  labial  suction.  After 
absorption  has  occurred,  and  with  the  appearance  of  the  convulsive  stage, 
chloral  hydrate  and  opium  by  the  stomach,  and  chloroform  or  ether  by 
inhalation,  may  be  given,  as  required.  Cannabis  Indica  is  reported  as 
successful  in  a  single  case.  || 

Glanders. — This  name  has  been  given  to  a  contagious  disease  which 
attacks  animals,  chiefly  horses,  and  is  communicated  to  man  by  inocu- 
lation of  the  peculiar  virus  upon  a  mucous  membrane  or  a  cutaneous 
wound.  In  horses  the  mucous  membranes  of  the  thi'oat  and  nose  are  first 
affected,  and  this  is  followed  by  enlargement  and  breaking  down  of  the 
lymphatic  glands  of  the  neck,  and  by  symptoms  of  general  sepsis,  meta- 
static abscesses,  and  cutaneous  ulcers.    It  is  not  only  communicable  from 

*  "  American  Journal  of  the  Medical  Sciences,"  1882,  p.  69. 
t  Flint's  "Practice  of  Medicine." 

I  "  Medical  Record,"  vol.  xxi,  p.  128. 

*  Loc.  cit. 

I  "Medical  Record,"  vol.  xxi,  p.  179. 


WOUNDS.  83 

an  animal  to  man,  but  from  one  person  to  anottier.  Schutz  and  Loffler, 
in  Koch's  laboratory,  have  recently  announced  the  discovery  of  the  hacil- 
li/s  of  glanders,  which  is  said  to  resemble  the  bacillus  tuberculosis. 
These  organisms  were  seen  by  Wassiliefl  in  the  blood  of  a  man  sick  wdth 
this  disease.  Inoculated  with  this  virus,  the  parts  about  a  wound  become 
rapidly  iniiamed  and  swollen.  Cellulitis,  lymphangitis,  and  adenitis 
ensue,  with  high  febrile  movement  and  the  usual  conditions  of  septi- 
caemia. Inoculated  upon  a.  mucous  surface,  the  morbid  process  is  prac- 
tically the  same.  Tiie  inflammation  spreads  rapidly,  and  the  adenitis 
and  ulcerations  occur  in  man  as  in  animals.  In  severe  cases  metastatic 
nodules  occur  in  the  skin,  not  infrequently  breaking  down  into  pustules. 
Abscesses  may  be  general.     In  the  severer  cases  death  is  the  rule. 

The  indications  in  treatment  are  to  sui:)port  the  tissues  by  all  possible 
measures  of  nutrition.  A  wound  freshly  inoculated  should  be  treated  as 
advised  in  rabies. 

Malignant  Pustule. — This  disease  in  man  results  from  the  inoculation 
of  a  peculiar  \drus  which  is  found  in  the  tissues  of  animals  infected  with 
a  micro-organism,  the  anthrax  bacillus  (Fig.  147). 
This  bacillus  is  beheved  to  be  the  disease-germ. 
Carnivora  are  rarely  susceptible.  The  virus  is 
intensely  toxic,  and  exceedingly  contagious.  By 
some  it  is  held  that  an  abrasion  of  the  integument 
or  mucous  surfaces  is  not  always  necessary  to  the 
invasion  of  the  germ.*  The  bite  of  an  insect  which 
has  been  feeding  upon  anthrax  carrion,  or  the  in- 
gestion of  infected  meat,  or  the  mere  contact  with 
Fio.  147.— (After  Sternberg.)  the  hair,  wool,  boues,  or  any  part  of  an  animal 
dead  with  anthrax,  is  dangerous. f  Tanners,  butch- 
ers, and  furriers  are  more  often  the  sufferers  from  this  disease  than  oth- 
ers. The  virus  retains  its  poteiicy  almost  indefinitely.  Sheep  allowed  to 
graze  in  localities  where  carcasses  of  cattle  dead  with  anthrax  have  been 
buried  many  years  acquire  the  disease  by  ingestion  of  germs  lodged  upon 
the  grass,  and  in  the  earth  over  these  graves.  Contagious  from  animal 
to  animal,  and  from  animal  to  man,  it  is  likewise  contagious  from  one  in- 
dividual to  another.  The  face  and  hands  are,  on  account  of  exposure, 
most  frequently  the  seat  of  the  inoculation.  The  symjjtoms  are  redness, 
swelling,  induration,  a  throbbing  sensation  and  pain  at  the  point  of 
contact  of  the  virus.  Within  twenty-four  hours  an  xilcer  usually  is  de- 
veloped in  the  center  of  the  indurated  area,  soon  followed  by  lymphan- 
gitis and  adenitis.  High  temperature,  rapid  pulse,  headache,  nausea, 
and  the  usual  condition  of  general  septiceemia,  follow  as  the  disease  pro- 
gresses. 

Microscopical  research  has  demonstrated  bacilli,  in  great  numbers, 
not  only  in  the  tissues  immediately  around  the  seat  of  contagion,  but,  also 
in  the  later  stages  of  the  disease,  a  general  dissemination  of  these  organ- 

*  Afrnew's  "  Surgery,"  vol.  i,  p.  214. 

■'{  "  New  York  Medical  Journal,"  1884,  p.  410. 


84  A  TEXT-BOOK   ON   SURGERY. 

isms.  Hfemorrliagic  infarctions  and  oedema  are  frequent  symptoms. 
When  the  disease  results  from  the  ingestion  of  the  poison,  the  diagnosis 
is  difficult.  Swelling  and  puffiness  of  the  face  have  been  observed,  with 
high  febrile  movement  and  great  prostration. 

Treatment. — Local  and  constitutional  measures  are  demanded — ex- 
cision or  free  incision,  and  the  application  of  a  strong  sublimate  solution 
(1  to  1,000).  Supporting  measures  are  demanded  when  the  infection  is 
general  and  prostration  is  threatened. 

Dissection  Wounds. — A  wound  is  not  apt  to  become  poisoned  from 
contact  with  the  tissues  of  a  cadaver  which  has  been  thoroughly  injected 
with  chloride  of  zinc,  arseniate  of  soda,  or  sublimate  solution.  Septic 
matter  from  non- injected  subjects  is  always  a  source  of  danger  when 
brought  in  contact  with  abrasions  of  the  skin  or  mucous  surfaces.  The 
contents  of  the  peritoneal  and  pleural  cavities  are  especially  virulent. 
The  fluids  from  persons  dead  from  any  septic  or  malignant  disease,  such 
as  erysipelas,  small-pox,  etc. ,  are  unusually  dangerous.  Patients  suffering 
from  suppurative  arthritis,  with  general  sepsis,  are  dangerous  subjects. 
In  a  recent  case  of  this  nature  in  Mount  Sinai  Hospital,  a  colleague  and 
one  member  of  the  house-staff  and  the  nurse  were  all  seriously  inoculated 
from  the  same  operation.  Susceptibility  varies  with  the  individual. 
Some  enjoy  lasting  immunity  under  all  conditions  of  exposure,  while 
others  are  easily  inoculated. 

Symptoms. — Inflammation  and  soreness  at  the  wound  are  first  noticed. 
In  a  few  days  lines  of  redness  extend  in  the  route  of  the  lymphatics,  and 
the  arm  (since  the  hand  is  usually  the  seat  of  the  primary  lesion)  becomes 
painful,  stiff,  and  hot.  The  epitrochlear  and  axillary  glands  enlarge,  and 
in  many  cases  suppurate.  Rigors,  fever,  headache,  aching  of  the  joints, 
coated  tongue,  and  other  symptoms  of  sepsis  follow.  The  patient  may 
pass  into  a  low  typhoid  state,  or  general  metastatic  abscesses  may  occur, 
ending  in  death. 

Treatment. — Ablution  of  the  wound  in  sublimate  solution  (1  to  500) 
and  suction  should  be  instantly  performed,  or  suction  alone  may  remove 
the  poison.  It  should  be  kept  open  and  washed  frequently.  Cold 
cloths  or  the  ice-bag  will  be  found  very  grateful  in  the  lymphangitis  and 
adenitis  which  follow  the  inoculation.  Caustics,  or  covering  in  an  abra- 
sion with  liquor  gutta-perchse,  collodion,  or  plaster  (except  for  protec- 
tion against  further  inoculation),  is  an  absurd  and  dangerous  practice. 
If  abscesses  form,  early  incision  is  demanded.  The  constitutional  reme- 
dies are  quinia,  tonics,  stimulants,  antipyrine,  judicious  feeding,  and 
ventilation. 

Erysipelas. — Erysipelas  is  a  contagious  as  well  as  an  infectious 
disease,  caused  by  the  invasion  through  an  abrasion  of  the  integument, 
or  by  the  mucous  surfaces,  of  a  specific  poison  or  virus.  The  pi-es- 
ence  of  an  almost  constant  micrococcus  (chain-coccus  of  Fehleisen)  in 
the  inflammatory  area  of  erysipelas  has  led  some  observers  to  consid- 
er this  organism  as  the  cause  of  the  disease.  That  it  has  not  been 
found,  in  some  instances  examined  by  careful  investigators,  might  seem 
to  disprove  this  theory.      The  weight  of  modern  opinion  is,  however, 


WOUNDS.  85 

largely  in  favor  of  the  existence  of  a  special  coccus  of  erysipelas.  Tt 
may  spread  from  one  infected  person  directly  to  another,  or  indirectly 
by  means  of  the  clothing  or  hands  of  an  intermediate  party.  It  is  char- 
acterized by  an  inflammation  of  the  skin  or  mucous  surfaces,  of  the  sub- 
cutaneous and  submucous  tissues,  and  at  times,  passing  the  barrier  of 
the  deep  fascia,  it  attacks  the  muscles  and  deeper  organs.  The  period 
of  incubation  varies  from  eight  to  twelve  hours  to  three  or  four  days. 
For  constitiitional  or  even  marked  local  symptoms  to  occur  within  twenty- 
four  hours,  however,  after  exposure  of  a  wound  to  the  virus,  is  the  excep- 
tion rather  than  the  rule.  In  the  large  majority  of  cases  the  symptoms 
declare  themselves  usually  between  twenty-four  and  forty-eight  hours. 
Locally  the  part  becomes  hot,  throbbing,  tense,  and  painful,  especially 
on  direct  pressure.  The  color  varies  from  a  pale  rose  to  a  bright  I'ed 
hue.  In  well-marked  cases  the  inflamed  integument  appears  to  be 
glazed,  and  the  limit  of  redness  is  regularly  and  sharply  defined.  When 
the  inflammatory  process  is  rapid,  and  the  integrity  of  the  circulation 
markedly  impaired,  the  bright  flush  of  the  skin  gives  way  to  a  dull 
mottled  discoloration.  Pressed  by  the  tip  of  the  finger,  the  skin  becomes 
pale,  but  the  color  returns  and  the  indentation  is  soon  effaced,  except  in 
those  cases  of  marked  oedema.  Lymphangitis  and  occasionally  phle- 
bitis occur.  The  spread  of  these  complications  is  indicated  by  lines  of 
redness  and  tenderness  leading  in  the  route  of  these  vessels.  In  some 
instances  vesicles  or  bullse  form  beneath  the  epidermis.  An  attack  of 
erysipelas  is  almost  always  ushered  in  by  one  or  more  chills,  or  by  dif- 
ferent and  recurring  chilly  sensations  or  rigors.  The  exacerbation  of 
temperature  varies  from  100°  to  104°  or  105°  F.  The  pulse  is  propor- 
tionately increased  in  frequency.  The  febrile  movement  and  constitu- 
tional symptoms  vary  with  the  character  of  the  attack.  In  simple 
cutaneous  erysij)elas  the  clinical  history  is  usually  mild.  In  the  cellulo- 
cutaneous  or  phlegmonous  variety  severe  and  fatal  sepsis  is  not  uncom- 
mon. Gangrene  is  occasionally  met  with  about  the  center  of  the  in- 
flamed zone,  and,  when  attacking  an  extremity,  the  circulation  may  be 
arrested  and  the  part  beyond  the  disease  sacrificed.  The  duration  may 
be  from  seven  to  ten  days  in  mild  cases  to  several  weeks  in  the  severer 
and  not  fatal  forms. 

Diagnosis. — Erysipelas,  within  the  first  twenty-four  or  forty-eight 
hours  of  its  appearance,  may  be  taken  for  dermatitis,  or  simple  erythema, 
phlebitis,  lymphangitis,  or  cellulo-dermatitis. 

Dermatitis  occurs,  as  a  rule,  from  local  irritation,  and  is  not  accom- 
panied by  any  of  the  constitntional  disturbances  which  always  occur  with 
erysipelas.  In  simple  inflammation  of  the  skin  the  color  is  red,  but  it 
never  has  the  glazed  appearance  which  is  always  present  in  a  typical 
erysipelas.  Erythema,  a  mild  form  of  dermatitis,  may  also  be  mistaken 
for  erysipelas.  In  erythema  papulatuTn  the  exposed  and  extensor  sur- 
faces, as  the  dorsum  of  the  hand  and  the  posterior  aspect  of  the  forearm, 
are  apt  to  be  involved.  There  is  no  wound  of  inoculation ;  very  slight,  if 
any,  infiltration  of  the  skin  proper.  Children  and  younger  adults  suffer 
most  frequently.     It  lasts  for  only  a  few  days,  then  fades  away,  leaving 


86  A   TEXT-BOOK   ON  SURGEKY. 

a  dry  scale  to  indicate  the  location  of  the  papule.  Owing  to  the  various 
shapes  and  the  different  shades  of  color  assumed  by  the  papules,  and 
efflorescence  of  the  erythema,  it  has  been  divided  into  erythema  annu- 
lare, erythema  gyratum,  and  erythema  iris.  * 

In  erythema  intertrigo  there  is  a  general  redness  of  the  skin  in  parts 
subjected  to  friction  or  irritation  from  perspiration.  Erythema  nodo- 
sum is  almost  peculiar  to  chlorotie  females.  The  color,  at  first  bright 
red,  soon  changes  to  a  dark  hue.  The  patches  are  oval,  elevated,  and 
nodular. 

Phlebitis  and  lymphangitis  are  more  severe  forms  of  inflammation 
than  those  just  given,  and  are  accompanied  with  constitutional  symptoms 
not  unlike  those  present  in  a  typical  erysipelas.  The  chief  point  of  diag- 
nostic value  relates  to  the  anatomical  arrangement  of  the  vessels,  for  in 
phlebitis  and  lymphangitis  the  lines  of  inflammation  and  discoloration 
travel  along  the  course  of  the  vessels  without  the  general  and  wide-spread 
efflorescence  of  erysipelas. 

Diffuse  cellulitis  oceurxing  from  a  poisoned  wound,  as  with  a  dissect- 
ing-knife,  or  after  the  bite  of  a  serpent,  will  offer  no  difficulty  in  diagnosis. 
It  may,  however,  occur  without  a  recognized  cause.  The  subcutaneous 
tissues  are  first  attacked,  and  the  skin  may  or  may  not  be  involved  in  the 
process  of  inflammation.  There  is  swelling  and  painful  tension  of  the 
part  affected,  and,  if  the  process  be  uninterrupted,  transudation  of  serum 
occurs,  causing  oedema,  and  giving  a  doughy  feeling  on  pressure.  Pus 
may  be  formed  in  quantity,  and  infiltration  become  extensive.  This 
result  is  more  apt  to  occur  in  diffuse  non-specific  cellulitis  than  in 
phlegmonous  erysipelas.  This  condition,  especially  when  the  skin  be- 
comes involved,  offers  considerable  difficulty  to  a  positive  diagnosis.  If, 
however,  the  peculiar  symptoms  heretofore  given  be  carefully  considered, 
and  a  comparison  instituted  between  them  and  the  phenomena  of  the 
various  diseases  which  may  simulate  or  complicate  erysipelas,  it  will  be 
found  that,  in  the  great  majority  of  cases,  a  correct  diagnosis  may  be 
made. 

Prognosis. — Simple  cutaneous  erysipelas,  as  a  rule,  is  not  a  dangerous 
disease.  In  several  epidemics  in  hospital  practice  I  have  never  seen  a 
fatal  case.  Occurring  about  the  face,  head,  or  neck,  the  prognosis  is  less 
favorable  than  when  the  inoculation  occurs  elsewhere.  When  it  compli- 
cates a  wound  in  a  patient  already  prostrated  by  hsemorrhage  or  surgical 
fever,  it  may  hasten  a  fatal  issue.  In  phlegmonous  or  cellulo-cutaneous 
erysipelas  the  prognosis  is  not  so  favorable.  Suppiiration  and  the  general 
infiltration  of  the  tissues  with  pus  and  inflammatory  products  induce  a 
condition  of  septicaemia  often  rapidly  fatal. 

Treatment. — In  an  outbreak  of  erysipelas  the  treatment  in  those 
attacked  is  both  local  and  constitutional,  while  in  others  strict  measures 
of  prophylaxis  should  be  instituted.  Immediate  isolatiou  should  be 
effected,  and  the  greatest  care  observed  to  prevent  contact  with  other 
subjects.     All  bedding,  furniture,  and  apparatus  used  upon  or  about  an 

*  Neumann,  '■Hand-Book  of  Skin  Diseases."     Bulkley.     D.  Appleton  &  Co.,  1872, 


WOUNDS.  87 

erysipelatous  patient  should  be  burned,  or  thoroughly  scrubbed  and 
soaked  in  a  solution  of  corrosive  sublimate  varying  in  strength  from 
1  to  500  to  1  to  1,000.  Any  instrument  subjected  to  contamination 
should  be  submerged  in  1  to  10  to  1  to  20  carbolic  acid,  and  after- 
ward thoroughly  dried.  The  walls  and  floors  of  a  ward  or  room  in 
which  an  outbreak  has  occurred  should  be  mopped  and  washed  in  the 
sublimate  solution.  The  attendants  upon  such  cases  should  be  ex- 
cluded from  all  possible  contact  with  other  individuals. 

When  a  physician  is  compelled  to  visit  a  case  of  erysipelas,  he 
should  wear  clothing  which  should  be  changed  immediately  after  leav- 
ing the  room,  which  precaution  should  be  emphasized  by  a  thorough 
disinfection  of  his  hands,  face,  beard,  and  hair  in  1  to  3,000  sublimate 
solution. 

The  local  measures  always  include  as  of  first  importance  the  invest- 
ment of  the  part  involved  with  sublimate  gauze  and  a  moist  dressing. 
Continuous  irrigation  of  cold,  tepid,  or  warm  sublimate  (1  to  5,000) 
may  be  added  to  the  loose  gauze  dressing,  or  not,  as  may  be  determined 
by  the  demands  of  any  case.  This  method  is  mainly  proj)hylactic. 
Cold  irrigation  will  be  most  generally  grateful.  Extreme  heat  or  cold, 
however,  should  be  used  with  caution  in  all  cases  where  the  circula- 
tion of  the  part  is  seriously  impaired  by  the  inflammatory  process. 
When  an  extremity  is  affected,  elevation  of  the  part  is  indicated.  Ten- 
sion should  always  be  relieved  by  puncture  or  incision,  even  when  sup- 
puration and  pus  infiltration  are  not  evident.  The  method  of  freely 
puncturing  or  making  multiple  limited  incisions  in  the  infected  area 
is  lately  highly  recommended,  and  is  worthy  of  trial.  A  loose  asep- 
tic gauze  dressing  should  follow.  The  principle  of  drainage  applies 
here  as  in  other  wounds,  and  the  free  outlet  of  all  purulent  matter  is 
essential.  Incisions,  when  practiced,  should  be  in  the  direction  of  the 
veins  of  the  part,  so  that  these  need  not  be  divided,  and  should  always 
extend  deep  enough  to  relieve  tension  and  to  give  free  exit  to  all  sep- 
tic matter.  The  method  of  injecting  carbolic  acid  into  the  skin  and 
subcutaneous  tissues,  at  a  distance  of  from  one  to  two  inches  from  the 
red  limit  of  the  erysipelatous  flush,  in  order  to  check  the  further  in- 
vasion of  the  disease,  is  of  doubtful  efficacy  and  propriety.  The  same 
should  apply  to  "firing"  with  the  actual  cauterj'  or  lunar  caustic  for 
the  same  purpose. 

The  constitutional  measures  look  to  the  support  of  the  patient, 
and  to  the  antagonism  of  the  specific  poison.  Since  constipation 
and  gastric  disturbance  are  the  rule,  a  saline  laxative  should  be 
given,  but  not  to  the  extent  of  producing  exhaustive  diarrhoea.  Pur- 
gation is  not  indicated  in  enfeebled  and  emaciated  subjects.  For 
the  rapid  pulse,  tincture  of  aconite-root  may  be  employed,  and  anti- 
pyrine,  10  to  20  grains  every  two  or  three  hours  imtil  the  tempera- 
ture falls  to  about  the  normal.  Tincture  of  the  chloride  of  iron,  8  to 
15  drops  three  or  four  times  a  day,  has  long  enjoyed  a  high  reputa- 
tion in  the  treatment  of  this  disease,  and  the  same  is  true  of  quinia  in 
full  doses. 


88  A  TEXT-BOOK  ON   SURGERY. 

Tetanus. — Tetanus,  or  "lock-jaw,"  is  now  believed  to  be  an  infectious 
disease  due  to  the  presence  of  a  special  bacillus,  the  bacilli  of  tetanus.,  or 
of  Nicolaier.  These  organisms  are  invariably  found  in  the  tissues  at  the 
wound  of  infection,  and  aj^pear  as  bristles  or  as  pins,  when  they  form 
spores  (Baumgarten).  They  are  found  in  the  soil  and  in  dusty  particles 
floating  in  the  air. 

Lock-jaw  has  been  produced  in  animals  by  inoculation  with  the  tis- 
sues of  man,  the  subject  of  tetanus.  Whether  the  central  lesion  {Qfiye- 
Utis)  is  directly  due  to  the  presence  of  these  organisms,  or  to  the  absorp- 
tion of  certain  ptomaines  which  are  generated  by  their  contact  with  the 
tissues,  is,  at  this  date,  not  definitely  settled. 

Any  lesion,  however  small  or  seemingly  insignificant,  and  upon  any 
portion  of  the  body,  may  serve  as  the  starting-point  of  this  affection. 
Wounds,  however,  of  exposed  surfaces,  as  of  the  hands,  feet,  and  face, 
are  especially  liable  to  become  infected. 

The  time  which  may  elapse  between  the  receipt  of  the  injury  and  the 
appearance  of  the  muscular  spasms  varies  from  a  few  hours  to  several 


weeks  ;  usually  within  the  first  three  weeks  after  the  injury.  The  earlier 
symptoms  refer  to  an  unusual  degree  of  irritation  and  pain  in  the  wound, 
which  is  apt  to  be  out  of  proportion  to  the  degree  of  inflammation  present. 
The  sense  of  pain  is  often  referred  along  the  sensory  tracts  toward  the 
centers.  Irritability,  a  sense  of  unusual  muscular  excitability,  a  feeling 
of  malaise  and  apx^rehension,  are  among  the  symptoms  which  xjrecede  the 
convulsive  attacks.  The  muscles  supplied  by  the  motor  filaments  of  the 
fifth  nerve  are  among  the  earliest  to  resjjond  to  this  abnormal  stimulus, 
hence  the  commonly  accepted  term  of  lock-jaio.  In  the  milder  cases  the 
tonic  spasms  may  be  altogether  confined  to  these  muscles.  In  severer 
cases  the  sense  of  distress  is  referred  to  the  epigastric  region,  and  this  is 
followed  by  tonic  muscular  contraction,  commencing  with  the  diaphragm, 
and  involving  in  quick  succession  the  muscles  of  the  jaws,  larynx,  and 
back  of  the  neck  and  dorso-lumbar  region.  Respiration  is  interrupted, 
the  expression  of  distress  is  extreme,  the  face  becomes  cyanotic,  and 
death  may  occur  from  fixation  of  the  resj)iratory  muscles.  The  chief 
distortion  is  that  of  more  or  less  complete  extension  of  the  spine  {opis- 


TETANUS.  89 

thoionos).  An  exaggerated  ilhisti'ation  of  this  condition  is  given  in  Fig. 
148,  from  the  well-known  picture  of  Sir  Charles  Bell.  When  the  tonic 
spasms  are  confined  to  the  anterior  muscles,  and  the  body  is  bent  forward, 
the  condition  is  known  as  emprostliotonos,  and  if  curved  laterally,  pleu- 
rothotonos.  The  spasm  continues  until  the  muscles  are  unable  longer 
to  contract,  when  a  gradual  and  partial  relaxation  occurs.  Successive 
attacks  follow  rapidly,  being  precipitated  by  the  slightest  cause,  as  the 
jar  communicated  by  walking  upon  the  floor,  or  the  contact  of  the  hair 
or  clothing  upon  the  hypersesthetic  integument. 

JSTotwithstanding  the  violent  nature  of  this  affection,  the  mind,  in  the 
great  majority  of  cases,  remains  clear  until  carbonic-acid  poisoning  occurs 
from  prolonged  fixation  of  the  respiratory  muscles.  The  pulse  and  tem- 
perature vary  between  great  extremes,  records  of  the  former  running 
from  the  normal  up  to  160  beats  per  minute,  and  of  the  latter  from  98  "5° 
to  112°  F.  The  intense  heat  which  is  premonitory  of  a  fatal  termination-, 
and  which  continues  for  a  considerable  while  after  death,  is  supposed  to 
be  due  to  coagulation  of  the  albuminoid  principle  of  muscle,  the  myosin 
(Fricke).  Death  may  take  place  in  a  single  paroxysm,  or  the  patient 
may  survive  a  number  of  attacks. 

Prognosis. — The  danger  of  death  diminishes  if  the  patient  survives 
the  fifth  day,  although  the  vast  majority  of  cases  end  fatally  before  this. 
The  gravity  of  the  prognosis  usually  depends  upon  the  violence  of  the 
paroxysms,  the  rise  in  pulse  and  temperature  being  also  proportional  to 
the  severity  of  the  convulsions.  The  period  which  elapses  between  the 
receipt  of  the  accident  and  the  appearance  of  the  tetanic  spasms  is  not 
without  importance  in  prognosis,  the  chances  of  recovery  being  increased 
with  the  longer  interval.  The  death-rate  in  those  cases  in  which  tonic 
spasms  occurred  within  two  weeks  after  the  injury  is  62  per  cent ;.  from 
14  to  21  days,  17  per  cent ;  21  to  44  days,  17  per  cent ;  50  per  cent  of  all 
fatal  cases  terminate  within  5  days  after  the  first  paroxysm  ;  33  per  cent 
from  the  fifth  to  the  tenth  day. 

Diagnosis. — Hysteria  is  more  apt  to  be  mistaken  for  tetanus  than 
any  other  disease.  In  hysteria  there  is  usually  no  elevation  of  tempera- 
ture, and  the  symptoms  of  great  and  acute  distress  are  wanting.  Hys- 
teria occurs  chiefly  in  females  ;  tetanus,  in  a  large  majority  of  cases,  in 
the  opposite  sex.  It  may  be  necessary  at  times  to  differentiate  between 
the  tetanoid  spasms  of  strychnia-poisoning  and  true  tetanus. 

Strychnia  tetanus  ensues  within  a  few  minutes  after  the  poison  has 
been  taken  ;  the  muscles  of  the  jaw  are  not  first  affected  as  in  tetanus, 
and  are  not  always  rigid  during  the  attack.  The  convulsive  movements 
in  strychnia-poison  are  of  short  duration,  and  complete  relaxation 
occurs,  while  in  tetanus  the  muscular  rigidity  is  continuous. 

Hydrophobia  may  be  distinguished  from  tetanus  in  the  character  of 
the  lesion  which  causes  it,  the  peculiar  clonic  or  interrupted  spasm  of 
the  muscles,  especially  those  of  the  larynx,  and  in  the  generally  longer 
period  of  incubation  in  rabies. 

Patliology. — The  lesion  of  tetaniis  is  believed  to  be  a  myelitis.  The 
gray  matter  of  the  cord  and  medulla  is  found  deeply  injected,  or  it  may 


90  A  TEXT-BOOK   ON  SURGERY. 

have  undergone  granular  degeneration.  In  some  instances  no  appreciable 
interference  with  the  nutrition  of  the  gray  matter  can  be  discovered. 

Treatment. — The  essential  feature  of  treatment  is  the  protection  of  all 
wounds  from  the  dangers  of  infection  by  the  thorough  application  of 
antiseptic  dressings  after  the  free  use  of  the  sublimate  solution.  Other 
local  measures  should  be  employed  to  reduce  the  irritation  in  the  wound. 
Relief  of  all  tension  should  be  secured  by  incisions,  if  necessary,  and  free 
discharge  should  be  maintained,  if  there  is  septic  matter  in  the  tissues. 

Amputation  when  the  wound  is  situated  upon  one  of  the  extremities, 
stretching  or  division  of  the  sensory  nerve  leading  to  the  si)ine,  excision 
of  the  wound,  and  other  surgical  measures,  have  been  tried,  but  without 
a  success  which  would  warrant  a  repetition  of  these  measures.  The  most 
perfect  quiet  is  to  be  maintained,  and  the  administration  of  concentrated 
nourishment  must  be  insisted  upon  in  the  intervals  of  the  attacks  ;  and 
rectal  alimentation  shoiild  be  practiced  if  there  is  inability  to  swallow. 

Chloral  hydrate  in  large  doses  has  been  successful  in  some  cases. 
From  thirty  to  forty  grains  have  been  given  and  repeated  at  intervals  of 
one  hour  and  a  half.*  The  inhalation  of  chloroform  is  also  highly  recom- 
mended. The  extract  of  cannabis  Indica  (Squires)  in  doses  of  gr.  ss. 
every  two  hours,  together  with  the  application  of  ice  to  the  spine,  is  a 
plan  of  treatment  highly  recommended. 

Ounsliot  Wounds. — Wounds  of  this  variety  may  properly  be  divided 
into  those  in  civil  and  those  in  military  practice.  In  civil  life  the 
wounds  inflicted  by  the  shot-gun,  small-bore  hunting-rifle,  pocket-pis- 
tol, and  toy  guns,  are  much  less  dangerous  than  those  made  by  the 
more  formidable  weapons  employed  in  warfare. 

With  the  exception  of  the  charge  projected  by  the  shot-gun  and  the 
small  hunting-rifle,  all  missiles  now  used  a]-e  conoidal  or  oblong  in  shape 
(Fig.  149). 

Projectiles  fired  from  ordnance  are  both  round  and  conoidal,  solid 
and  hollow,  the  latter  being  usually  explosive.  Grape,  canister,  bombs, 
and  some  solid  shot,  are  spherical,  while  most  of  the  shells  are  cylindro- 
conoidal. 

A  gunshot  wound  is  always  contused  or  lacerated.  It  may  be  simple 
or  complicated :  simi)le  when  the  missile  alone  passes  through  the  tissues  ; 
complicated  when  fragments  of  cartridge,  wadding,  powder,  clothing,  or 
other  foreign  matters  are  carried  in  with  it. 

The  degree  of  laceration  made  by  a  gun-projectile  is,  as  a  rule,  in  an 
inverse  ratio  to  the  rapidity  of  its  j)rojection.  It  may  also  depend  upon 
the  shape  of  the  missile,  and  the  additional  destruction  caused  by  dis- 
placed fragments  of  bone,  etc.  A  conoidal  projectile  is  more  destructive 
than  one  wliich  is  spherical,  for  when  in'  its  transit  the  point  meets  with 
resistance,  it  tends  to  turn  over  and  over  on  its  long  axis,  loses  in  great 
part  its  axial  rotation,  and  thus  plunges  through  the  tissues.  When  a 
ball  passes  in  and  out  of  the  body,  it  will  be  found  that  the  wound 
of  entrance  is  smaller  than  tliat  of  exit,  and  is  seemingly  much  smaller 

*  Hammond,  "  Diseases  of  the  Nervous  System."     D.  Appleton  &  Co. 


GUNSHOT   WOUNDS. 


91 


than  the  projectile.  The  infolding  of  the  skin  and  its  elasticity  wUl 
acconnt  for  the  small  size  of  the  entrance.  The  diminution  of  the 
momentum,  and  the  tumbling  of  the  projectile  as  it  plunges  through 
the  tissues,  together  with  the  non-resistance  of  the  skin  at  the  exit,  will 

account  for  the  larger  size  of  this 
opening.  When  a  projectile  f)ass- 
es  completely  through  the  tissues 
there  is  usually  a  single  oj)ening 
of  exit.  Occasionally  the  object 
is  divided  after  entrance,  and 
makes  two  or  more  holes  of  exit, 
or  one  part  of  the  bullet  may 
lodge  and   the  other  pass  out. 


Fig.  149. — Table  of  weights  (in  grains)  of  the  balls  at  present  in  use  in  the  armies  of  various  nations.  TVith 
the  exception  of  No.  6,  the  cuts  approximate  the  actual  size  of  the  missiles.  1,  Springfield  rifle,  500 
grains  (Agnew).  2,  Enfield  rifle,  530  grains  (Agnew).  3,  Austrian  riile  (old),  400  grains  (Agnew). 
4,  Chassepot  rifle,  387x  grains  (Fischer).  5,  Needle-gun,  530  grains  (Agnew).  6,  Mitrailleuse,  840 
grains  (Agnew).  7,  Bavarian  rifle,  386  grains  (Fischer).  8,  Snider  rifle,  smout  400  grains.  9,  Musket- 
ball,  480  grains  (Agnew).  10,  Belgian  rifle,  385  grains  (Fischer).  11,  Martiui-Henry  rifie,  485  grains 
(Fischer).  12,  Italian  rifle,  310  grains  (Fischer).  13,  Netherland  rifle,  337  grains  (FLsclier).  14,  Austrian 
rifle  (new),  372grains  (Fisclier).  15,  Russian  rifle,  372grains  (Fischer).  IG,  Swissrifle,  310 grains  (Fischer). 

Fragments  of  bone  or  teeth  displaced  by  a  missile  may  be  driven  out 
through  the  integument. 

If  the  velocity  of  a  missile  is  great,  and  the  tissues  traversed  offer  no 
special  resistance,  the  wound  of  exit  will  be  in  the  direct  line  of  that  of 
entrance.  Bodies  traveling  with  diminished  velocity  or  meeting  with 
formidable  resistance  will  be  deflected,  and  may  jjursue  a  most  unex- 
pected course.  Instances  are  recorded  of  bullets  which  have  made  a  half 
or  the  entire  circuit  of  the  body,  passing  just  beneath  the  skin.  Still 
more  remarkable  are  the  instances  of  extensive  fracture  of  bones  which 
have  been  produced  without  any  evidence  of  injury  to  the  integument. 
Longmore  *  relates  the  case  of  a  soldier  who  had  the  whole  shaft  of  the 


Holmes's  "Surgery,"  vol.  ii,  p.  134.     William  "Wood  &  Co.,  1875. 


92  A  TEXT-BOOK   ON  SURGERY. 

Immerus  shattered  by  a  cannon-ball,  yet  tlie  skin  remained  as  white  and 
as  sound  as  if  it  had  not  been  touched.  Numerous  instances  of  similar 
lesions  are  recorded. 

Treatment. — As  with  all  other  wounds,  the  arrest  of  hsemorrhage  is 
the  iii'St  indication  in  gunshot  injuries.  The  various  means  to  accom- 
plish this  end  have  already  been  given.  It  should  be  the  recognized 
duty  of  the  profession  to  instruct  the  general  public  in  the  use  of  the 
simpler  means  for  arresting  hsemorrhage.  In  military  service  each  soldier 
should  be  taught  by  actual  demonstration  where  and  how  to  make  com- 
pression in  order  to  control  the  blood-supply  to  a  part.  In  actual  warfare 
the  vessels  should  be  outlined  by  nitrate-of-silver  tracings,  and  with  especial 
indications  at  those  points  where  pressure  will  prove  most  efficient.  The 
ready  construction  of  a  tourniquet  by  means  of  a  belt,  coat-sleeve,  bridle- 
rein,  etc.,  tied  around  the  limb  at  the  proper  place,  and  then  twisted  by 
a  bayonet,  sword,  gun-barrel,  or  stick,  is  an  important  lesson  for  an 
emergency.  Next  in  order,  and  no  less  essential  in  the  successful  man- 
agement of  a  gunshot  wound,  is  cleanliness  and  drainage.  In  the  best- 
regulated  armies  of  to-day  each  soldier  carries  in  his  cartridge-box  a  well- 
protected  ball  of  iodoformized  gauze,  with  the  instructions  to  lay  this  over 
the  wound  as  soon  as  possible,  and  to  hold  it  there  by  a  belt  or  bandage 
until  the  surgeon  arrives.  In  the  antiseptic  treatment  of  these  injuries 
irrigation  with  1  to  3,000  sublimate  solution  is  thoroughly  done.  All 
foreign  matter  or  fragments  of  bone  or  destroyed  tissues  are  removed, 
bone,  catgut,  or  rubber  drains  inserted,  and  the  regulation  antiseptic 
dressing  applied. 

When  sublimate  solution  can  not  be  had,  1  to  20  to  30  carbolic  acid 
is  next  in  order  of  preference  ;  and,  if  neither  of  these  articles  is  avail- 
able, the  freshest  and  purest  water  should  be  employed  ;  and,  when  time 
allows,  this  should  be  boiled,  and  used  at  110°  F. 

Following  a  serious  gunshot  or  other  injury  (or  at  times  a  violent 
emotion  without  any  appreciable  lesion),  a  condition  of  prostration  or 
partial  collapse  occurs,  which  is  known  as  sliocTt.  Shock  may  be  defined 
as  a  condition  of  collapse  resulting  from  physical  injury  or  mental  emo- 
tion (one  or  both)  whereby  the  functions  of  the  nerve-centers  are  more  or 
less  completely  suspended.  The  degi-ee  of  shock  is  often  determined  by 
individual  susceptibility,  and  is  not  always  in  proportion  to  the  sevei-ity 
of  the  injury.  The  symptoms  are  pallor,  coldness  of  the  skin,  thready, 
irregular,  or  rapid  jjulse,  nausea,  vomiting,  clammy  perspiration,  and  an 
anxious  and  fixed  expression. 

Judicious  stimulation  is  the  great  indication,  for,  while  reaction  must 
be  brought  about,  the  quantity  of  stimulants  should  be  kept  at  the  pos- 
sible minimum,  for  an  excess  will  only  add  to  the  fever  of  reaction.  Eye 
whisky  by  the  mouth,  rectum,  or  hypodermically,  should  be  preferred. 

Hot  bottles,  w-armed  blankets,  friction,  etc.,  are  useful  adjuvants  in 
the  treatment  of  shock. 

The  advisability  of  searching  for  a  gunshot  missile  wliich  has  lodged 
in  the  body,  or  which  has  traversed  any  of  the  cavities,  as  well  as  the 
treatment  of  wounds  of  special  organs,  will  be  discussed  hereafter. 


CHAPTER  VII. 

BUB]N"S   AND   SCALDS. — FROST-BITE. 

Burns  and  scalds  are  classified  in  degrees  varying  from  the  mildest 
form,  which  produces  a  simple  inflammation  of  the  epidermis,  to  the  most 
severe  form,  which  destroys  all  the  tissnes  or  organs  of  a  jDart.  The 
gravity  of  the  prognosis  is  usnally  in  proportion  to  the  extent  of  surface 
of  the  integument  destroyed  rather  than  to  the  depth  of  the  destructive 
process.  Burns  of  the  head  and  face  are  most  dangerous ;  those  of  the 
extremities  least  grave.  Recovery  is  exceptional  after  destruction  of  one 
third  of  the  cutaneous  surface.  Death  may  result  from  shock,  ulcer  of 
the  duodenum,  or  exhaustion  from  prolonged  suppuration  and  septic 
absorption. 

The  history  of  a  slight  burn  or  scald  involving  only  a  limited  area  of 
the  integument,  and  not  extending  beyond  the  skin,  is  simply  one  of 
local  disturbance.  Cold-water  immersion  is  the  indication  in  treatment. 
When,  however,  a  considerable  extent  of  tissue  is  involved,  symptoms  of 
profound  constitutional  disturbance  rapidly  supervene.  The  patient  is 
seized  with  chills  or  rigors,  suffers  excruciating  pain,  betrays  in  his 
expression  the  extreme  anxiety  felt  as  to  his  condition,  and  sinks  into  a 
condition  of  collapse,  which  is  often  the  prelude  to  a  fatal  issue.  When 
not  rapidly  fatal,  the  duration  of  this  stage  is  fi'om  six  to  thirty-six 
hours.  It  is  followed  by  the  stage  of  reaction  and  inflammation.  The 
character  of  the  febrile  movement  depends  upon  the  extent  of  the  destruc- 
tion of  the  tissues,  and  upon  the  concurrence  of  certain  lesions  of  the 
thoracic  and  abdominal  viscera.  Inflammation  of  the  duodenal  glands, 
and  the  formation  of  ulcer  with  perforation,  is  not  of  infrequent  occur- 
rence during  the  second  week  after  the  accident.  Peritonitis,  pleuritis, 
or  pneumonitis  may  add  to  the  gravity  of  the  prognosis.  Laryngitis 
and  bronchitis  are  apt  to  follow  the  efforts  at  inspiration  in  the  presence 
of  scalding  steam. 

Treatment. — The  immediate  indication  is  to  relieve  pain  by  the  admin- 
istration of  morphia  hypodermically,  or  some  form  of  opium  by  the  rec- 
tum or  stomach.  Stimulation  with  whisky  or  brandy  by  enema,  or  by  the 
mouth,  is  also  indicated  to  prevent  collapse,  or  to  modify  the  intensity  of 
shock  which  is  apt  to  follow  a  scald  or  burn.  The  use  of  both  opium  and 
alcohol  should  be  made  with  a  certain  degree  of  caution,  for  there  is 
danger  from  a  too  profound  narcosis  with  the  former,  while  alcohol  in 


94  A   TEXT-BOOK   ON   SURGERY. 

excess  will  -annecessarily  add  to  the  fever  of  reaction,  which  always  fol- 
lows if  the  patient  should  rally  from  the  shock. 

The  clothing  should  be  carefully  removed,  and  the  burned  surface 
shielded  from  the  atmosphere  by  an  immediate  application  of  a  mixture 
containing  equal  parts  of  linseed-oil  and  lime-water.  If  this  preparation 
can  not  be  obtained,  a  coating  of  ordinary  white-lead,  as  mixed  for  use  in 
painting  dwellings,  is  an  efficient  protective  when  poured  over  the  burn. 
Flour  sprinkled  over  until  all  the  excoriated  surface  is  well  hidden  is  a 
method  of  treatment  which  may  be  carried  out  in  almost  any  emergency. 
Rubber-tissue  protective  laid  over  the  raw  surface,  and  cotton  batting 
applied  on  top  of  this,  is  equally  efficient.  Lint  dipped  in  2-per-cent  car- 
bolized  oil  may  be  used  directly  on  the  wound.  Any  great  degree  of 
pressure  should  not  be  jiermitted  upon  the  excoriated  surfaces.  In  the 
not  infrequent  form  of  burn  in  which  the  back  and  posterior  aspects  of 
the  extremities  are  chiefly  involved,  the  prone  position  should  be  main- 
tained. 

When  suppuration  and  sloughing  commence,  great  cleanliness  should 
be  observed,  to  prevent  the  absorption  of  septic  matter.  The  dressings 
should  be  changed  as  often  as  the  thermometer  indicates  septiceernia,  but 
not  oftener.  Absorbent  cotton  pellets  moistened  in  1  to  3,000  sublimate 
should  be  used  in  cleansing  the  burned  surface.  A  mixture  of  vaseline 
(the  white  variety  is  preferable)  and  iodoform,  in  the  proportion  of  §  j  of 
the  former  to  3  j  of  the  latter,  is  a  useful  dressing  in  the  stage  of  granula- 
tion. This  should  be  applied  on  surgeon's  lint,  and  covered  over  with 
rubber  protective.  It  often  becomes  necessary  to  arrest  exuberant  granu- 
lations by  the  free  use  of  lunar  caustic,  or  the  projecting  buds  may  be 
clipped  off  with  the  scissors — a  method  objectionable,  however,  in  the 
bleeding  which  always  follows  this  practice.  Compression  by  strips  of 
adhesive  (diachylon)  plaster  is  a  better  method  of  repressing  the  over- 
grown granulation-tissue.  When  the  destruction  of  integument  has  been 
so  extensive  that  cicatrization  can  not  be  effected  on  account  of  the  ten- 
sion of  the  part  involved,  the  transplantation  of  skin  should  be  practiced. 
The  various  methods  are  grafting,  sliding,  or  transplantation  in  mass. 

Grafting  may  be  done  by  clippings  about  one  twentieth  of  an  inch  in 
diameter,  and  cut  out  so  that  only  the  epidermis  and  Malpighian  layers 
are  included.  The  epidermis  is  pinched  up  with  a  pair  of  mouse-toothed 
forceps,  and  clipped  off  close  to  the  forceps  with  sharp  curved  scissors. 
A  spot  of  the  granulating  surface  free  from  pus  is  selected,  and  the  graft 
laid  on  bottom-side  down  and  pressed  snugly  into  the  granulating  bed. 
A  similar  graft  for  every  quarter-inch  of  surface  will  siiffice.  These 
should  be  left  uncovered  from  one  half  to  one  hour.  A  layer  of  pro- 
tective is  then  laid  over  the  entire  surface,  and  a  light  sublimate-gauze 
dressing  applied,  held  on  with  a  roller  or  adhesive  strips.  This  dressing 
should  remain  unmolested  for  at  least  forty-eight  hours,  in  order  to  give 
the  grafts  time  to  take  hold,  and,  when  the  dressing  is  changed,  great  care 
should  be  taken  to  prevent  their  dislodgm^ent.  Water  should  not  be 
used  in  the  dressing.  At  the  end  of  about  the  third  day,  if  the-  graft  has 
"taken,"  a  bluish  white  spot  will  be  seen,  the  color  fading  away  gradu- 


BURXS  A^'D   SCALDS. 


95 


ally  at  the  edges  until  it  is  merged  in  the  general  graniilating  mass. 
Grafts  sitiiated  near  the  skin  wiU  unite  and  proliferate  more  rapidly  and 
surely  than  those  farther  out  in  the  wound. 

When  an  extensive  area  is  to  be  grafted  over,  the  method  of  Thiersch 
should  be  employed.  The  granulating  surface  should  be  dry  and  thor- 
oughly clean.  With  the  patient  anesthetized,  some  spot  of  the  body 
covering  should  be  washed,  shaved,  and  thoroughly  disinfected.  "With 
a  sharp  razor,  shave  off  in  flakes  or  sheets  the  epidermal  layer  so  thin 
that  at  all  points  it  is  clearly  translucent — in  fact,  no  thicker  than  the 
finest  soft  paper.  Moistening  the  skin 
and  instrument  as  the  cutting  is  done 
wOl  facilitate  the  lifting  of  a  thinner  sec- 
tion. These  pieces  are  laid  snugly  upon 
the  granulating  surfaces  until  all  are  cov- 
ered. They  are  held  in  position  by  adhe- 
sive strips  and  a  moist  aseptic  dressing. 

Dr.  J.  H.  Girdner*  has  demonstrated 
that  pieces  of  skin  taken  from  a  healthy 
man  six  hours  after  death  by  accident, 
"cut  into  a  great  many  small  pieces,"' 
and  laid  upon  a  healthy  granulating 
surface,  will  become  revitalized.  The 
results  of  this  demonstration  are  very 
valuable  (Fig.  150). 

Transplantations  of  skin  in  large 
pieces  by  entire  removal,  or  with  a  ped- 
icle left  until  the  vascular  supply  is  es- 
tablished between  the  granulating  sur- 
face and  the  trans]3lanted  integument. 
may  also  be  successfully  accomplished. 
It  is  essential  that  the  skin  which  is 
completely  detached  should  be  clipped 
or  scrajjed  on  its   under  surface  until 

only  the  Malpighian  layer  and  epidermis  are  left.  The  presence  of  fat  on 
the  reticulated  corium  will  prevent  success.  When  sliding  is  attempted, 
it  is  essential  that  the  pedicle  should  be  of  good  width,  and  that  the  ten- 
sion on  it  should  not  be  great,  so  that  the  integrity  of  the  blood-supply 
may  not  be  interfered  with,  and  sloughing  ensue.  Upon  the  face  and 
neck,  where  the  vascularity  is  so  great,  a  smaller  pedicle  may  be  used, 
and  greater  tension  employed  than  on  other  j^ortions  of  the  body. 

When  there  is  not  sufficient  integument  immediately  about  a  burn  to 
supply  the  want,  the  flap  may  be  secured  from  some  other  portion  of  the 
body.  Thus  in  a  case  of  extensive  destruction  of  the  integument  on  the 
front  of  the  leg,  I  have  succeeded  in  covering  in  the  surface  by  turning  a 
flap  from  the  posterior  aspect  of  the  opposite  leg.  leaving  a  wide  pedicle, 
and  fastening  the  two  members  in  an  immovable  position,  so  that  the 
flap  remained  in  its  proper  place  and  free  from  strain.  After  about  ten 
days  the  pedicle  may  be  divided.  In  the  case  of  a  boy  who  had  been 
*  "Medical  Record,"  vol.  xx,  p.  119. 


v-4 


U 


96 


A  TEXT-BOOK   ON   SURGERY. 


severely  burned  in  the  hand  and  forearm,  and  where  the  cicatricial  con- 
tractions displaced  the  fingers,  deformed  the  hand,  and  threatened  am- 
putation of  the  member  by  obstruction  of  the  radial  and  ulnar,  I  did 
the  following  operation  with  success  :  All  the  cicatricial  tissue  about  the 
wrist  and  arm  was  dissected  off  down  to  the  tendons  and 
bones,  which  were  in  good  condition.  Two  parallel  incis- 
ions, six  or  seven  inches  long  and  four  inches  apai't,  were 
then  made  from  the  ensiform  cartilage  down  to  the  umbili- 
cus, and  the  strip  of  skin  dissected  up  in  the  middle  and 
left  attached  at  both  ends.  When  the  small  amount  of 
bleeding  had  been  arrested,  the  hand  was  slid  beneath  this 
fiap,  the  under  surface  of  which  was  brought  in  contact  with 
the  raw  surface,  where  the  cicatricial  tissue  was  removed 
from  the  arm  and  held  in  2:)lace  by  stitching  the  edges  to- 
gether with  silk.  lodoform-sublimate  dressing  was  applied, 
and  the  hand  and  arm  held  immovable  by  adhesive  plaster. 
Fig.  151  shows  the  condition  of  the  hand,  and  Fig.  152  the 
method  of  transplantation.  On  the  tenth  day  the  strip  of  skin  was  di- 
vided above  and  below,  and  the  ribbon  folded  around  the  wrist  and 
stitched  in  position.  The  operation  succeeded,  and  amputation  was  avoid- 
ed. A  second  similar  operation  was  done  to  restore  the  integrity  of  the 
jjalm.  In  all  cases  of  transplanting  skin  no  more  of  the  subcutaneous  tis- 
sue should  be  lifted  with 
the  integument  than  is  nec- 
essary for  the  vitality  of 
the  flap.  In  short  fla2:)s  a 
very  thin  dissection  should 
be  effected  ;  in  longer  ped- 
icles a  good  deal  of  tissue 
should  be  left  to  insure  the 
safety  of  the  blood-vessels. 
Transplanting  in  mass, 
in  which  the  piece  of  in- 
tegument, at  least  one  inch 
in  surface-measurement,  is 
entirely  severed  from  its 
original  attachment,  and 
laid  upon  the  granulating 
surface,  is  not  so  successful 
^  .,  as  the  preceding  methods. 

^  '''^  The  smaller  grafts  are  much 

preferable.     When  this  op- 
eration is  done,  the  piece 
to  be  transferred  should  be 
ji^  trimmed  or  scraped  so  thin 

that  nothing  but  the  epi- 
^,     ,,„    .^,        ,  dermis  and  Malpighian  lay- 

iiQ.  152.— The  authors  cose  ot  tran.splantation  from  the  .  _^  -^    ^         .         "^  „ 

abdomen  to  the  arm.  er  remauis.    Destruction  of 


FROST-BITE.  .97 

tissue  by  acids  or  alJcalies  requires  no  special  consideration  be- 
yond the  adoption  of  measures  to  neutralize  the  excess  of  the  agent 
in  the  part  involved.  The  after-treatment  does  not  differ  from  that 
of  the  granulating  surfaces  of  burns  and  scalds  fi'om  fire,  boiling  water, 
or  steam. 

Frost- Bite. — The  effect  of  prolonged  and  extreme  cold  upon  the 
animal  tissues  is  to  cause  occlusion  of  the  capillaries,  loss  of  sensa- 
tion, and  death  by  gangrene.  The  treatment  is  to  attempt  a  gradual 
restoration  of  the  circulation  by  friction  in  a  low  temperature.  A 
part  of  the  body  benumbed  by  cold  should  never  be  submitted  sud- 
denly to.  a  high  temperature,  but  should  be  bathed  and  rubbed  in  snow 
or  cold  water,  the  temperature  of  which  is  slowly  elevated.  When 
gangrene  results,  amputation  is  demanded  after  the  line  of  demarkation 
is  established. 

Furuncle.  —  A  boil  is  a  circumscribed  inflammation,  commencing 
usually  in  the  hair  follicles  and  sebaceoiis  glands,  and  extending  to  the 
subcutaneous  tissues,  in  which  it  may  at  times  orig-inate.  The  chief 
cause  is  either  a  traumatic  or  idiopathic  inflammation  in  the  glandular 
apparatus  of  the  skin,  and  the  arrest  of  the  nutrition  of  the  part  by 
obstruction  of  the  capUlaries  by  pressure  from  without  or  by  embolism 
or  thrombosis  from  within.  The  inflammation  spreads  to  the  surround- 
ing tissues,  and  localized  gangrene  ensues.  Boils  occur  very  frequently 
during  the  history  of  certain  diseases,  as  diabetes  mellitus,  tuberculosis, 
scrofula,  derangements  of  nutrition,  etc. 

The  diagnosis  is  not  difficult,  being  chiefly  between  carbuncle  and  the 
localized  necrosis  in  certain  forms  of  sypliilitic  gumma  of  the  skin. 
From  carbuncle  it  may  be  differentiated  by  the  more  acute  inflammatory 
process  of  the  furuncle,  the  single  point  of  suppuration,  the  well-defined 
limit  of  the  redness,  and  the  acute  character  of  the  pain.  In  carbuncle 
the  inflammation  extends  more  widely  and  deeper,  the  induration  is 
greater,  there  are  several  points  of  suj^puration,  and  the  febrile  symptoms 
more  appreciable.  The  sypliilitic  lesions  will  be  recognized  from  the 
history  of  the  disease.  The  treatment  looks  to  an  early  relief  from 
tension  in  the  integument,  and  the  separation  and  discharge  of  the  slough 
and  pus.  Incision  should  be  performed  at  once.  The  judicious  use  of 
cocaine  hypodermically  will  prevent  pain,  and  much  suffering  will  be 
avoided  by  prompt  action.  The  application  of  cold  or  heat  is  at  times 
useful.  Poultices  are  almost  universally  employed  to  soften  the  skin  and 
hasten  the  discharge  of  the  dead  tissue.  It  is  a  waste  of  time  to  wait  for 
so  slow  a  process.  After  incision  a  warm,  moist  sublimate  flaxseed  poul- 
tice or  dressing  should  be  applied,  and  continued  until  a  cure  is  effected. 

The  constitutional  treatment  should  be  directed  to  the  correction  of 
any  existing  dyscrasia.  The  preparations  of  iron  and  mercury  are,  in 
my  opinion,  the  best  general  remedies.  Tonics,  good  food,  regulation  of 
the  alimentary  apparatus,  and  good  hygiene,  are  essential.  Sulphide  of 
calcium,  gr.  -^  to  \,  three  or  four  times  a  day  ;  arsenic,  the  iodides,  cod- 
liver  oil,  with  the  hypophosphites  of  lime  and  soda,  are  among  the 
remedies  most  recommended. 
7 


98'  A  TEXT-BOOK   ON  SURGERY. 

Carbuncle. — This  disease — which,  as  Prof.  A.  E.  Robinson  *  remarks, 
has  been  misnamed  '■^anthrax'''' — is  characterized  by  an  inflammatory 
process  of  a  low  order,  involving  chiefly  the  skin  and  the  connective  tis- 
sues immediately  beneath  it,  and  in  some  instances  extending  into  the 
deeper  organs.  Carbuncle  is  a  disease  of  malnutrition.  The  process  is 
akin  to  that  of  furuncle,  though  indicative  of  a  more  depraved  condition 
of  the  tissues.  The  cause  is  capillary  thrombosis  or  embolism  and  subse- 
•  quent  inflammation  spreading  from  the  necrotic  focus.  Gangrene  always 
occurs,  and  the  inflamed  area  breaks  down  in  several  places,  giving  dis- 
charge to  pus  usually  in  small  quantity,  as  well  as  to  dead  tissue.  It  is  apt 
to  occur  as  a  complication  of  the  same  diseases  with  which  furuncles  are 
seen^diabetes  mellitus,  tuberculosis,  scrofula,  etc.  It  is  apt  to  occur  in 
parts  of  the  economy  subjected  to  more  than  ordinary  irritation,  as  the 
back  of  the  neck,  where  the  collar  presses,  and  in  the  gluteal  region. 

The  symptoms  of  this  affection  are  a  sense  of  malaise,  loss  of  appetite, 
headache,  fever,  varying  in  intensity,  which  is  followed  by  or  accom- 
panied with  a  deep-seated  and  severe  pain  in  and  about  the  local  expres- 
sion of  the  disease.  The  skin  at  this  point  becomes  tense,  injected, 
doughy  to  the  touch,  throbbing  and  painful ;  the  epidermis  becomes 
lifted  at  various  spots  in  the  inflamed  area,  vesicles  form,  localized  gan- 
grene occurs,  and  the  dead  matter  sloughs  away.  Not  infrequently  the 
necrotic  process  rapidly  extends  through  the  areolar  tissue  beneath  the 
skin  some  time  before  the  integument  breaks  down.  The  extent  of 
necrosis  varies  under  different  conditions,  and  may  be  general  or  limited. 
The  constitutional  symptoms  are  determined  by  the  amount  of  septic 
absorption  and  the  degree  of  pain  experienced. 

The  process  of  repair  is  by  granulation,  the  development  of  an  em- 
bryonic tissixe  which  advances  from  the  sides  and  bottom  of  the  cavity 
as  the  slough  is  carried  away.  As  to  the  length  of  time  carbuncle  may 
last,  nothing  jDositive  can  be  stated.  Usually  from  three  to  seven  weeks  ; 
at  times,  when  the  process  is  subacute,  several  months. 

The  prognosis  depends  upon  the  condition  of  the  patient,  the  age, 
the  location  and  extent  of  the  lesion,  and  the  ability  of  the  capillaries 
and  lymphatics  to  resist  septic  absorption.  Occurring  in  diabetes  or  any 
dangerous  malady,  it  hastens  a  fatal  issue.  ■  Situated  upon  the  face,  the 
gravity  of  the  prognosis  is  increased.  This  is  in  great  part  due  to  the 
intense  pain  which  follows  an  invasion  of  that  part  of  the  body  in  which 
the  trifacial  nerve  is  distributed.  When  located  on  the  thorax,  the 
pleura  may  become  involved,  thereby  causing  a  grave  complication. 

The  treatment  should  look  to  the  immediate  improvement  of  the 
patient's  vitality  by  all  available  means.  The  local  treatment  should  be 
directed  to  the  relief  of  tension,  the  arrest  of  the  invasion,  and  the  dis- 
charge of  septic  matter. 

The  only  i^ossible  objection  to  early  and  free  incision  is  haemorrhage, 
and  the  operator  has  only  to  decide  between  the  danger  of  sepsis  from 
delayed  drainage  on  the  one  hand,  and  that  of  loss  of  blood  on  the  other. 
To  my  mind,  the  fear  of  hsemorrhage  is  unfounded,  and  should  not  cause 
a  delay  in  making  the  incisions.     The  patient  should  be  anaesthetized, 

*  "  Manual  of  Dermatology,"  1884. 


ULCERS. 


99 


it  is  deficient. 


and  tlie  indurated  mass  incised  well  down  to  the  bottom  in  several  direc- 
tions. Crucial  cuts,  or  several  parallel  incisions,  or  lines  radiating  from 
the  center,  may  be  made  as  the  location  and  size  of  the  carbuncle  may 
indicate.  If  undermining  has  been  extensive,  drainage-tubes  should  be 
employed.  Hemorrhage  may  be  controlled  by  packing  with  sublimate 
gauze.  The  after-treatment  should  be  hot  or  warm,  sublimate-gauze 
dressings  applied  loosely,  and  covered  in  with  protective  or  OLL-sUk. 
Poultices,  if  employed,  should  be  made  Avith  sublimate  solution,  as  here- 
tofore directed. 

Ulcers. — An  ulcer  is  the  result  of  molecular  death  in  the  integument 
or  mucons  membrane,  and  the  underlying  areolar  or  submucous  tissue. 
The  process  of  necrobiosis  may  at  times  extend  below  the  deep  fascia. 
Of  whatever  variety,  an  ulcer  is  caused  by  a  failure  of  nutrition  in  the 
part  affected.  The  an-est  of  nutrition  may  be  local,  as  in  the  ulcer  of 
chancroid  or  with  a  varicose  condition  of  the  veins,  or  constitutional,  as 
in  the  late  manifestations  of  syphilis,  in  scorbutus,  etc.  Occurring  with 
a  dyscrasia,  ulcers  are  even  then  more  apt  to  occur  in  parts  of  the  body 
subjected  to  abnormal  interference  with  the  circulation. 

Specific  ulcers  will  be  considered  with  the  diseases  of  which  they 
form  a  part.     Ulcers  may  be  divided  into  two  clinical  groups — the  active 
and  indolent.     In  one,  the  material  for  repair  is  in  excess  ;  in  the  other, 
The  most  frequent  seat  of  ulcer  is  upon  the  anterior 
aspect  of  the  tibia  at  its  middle  and  lower  portions. 
They  occur  almost  always  in   the  aged,  and   chiefly 
among  the  poorly  fed  and  laboring  classes,  where  the 
erect  posture  is  of  necessity  maintained  for  many  suc- 
cessive hours.     Varicosities  of  the  veins  of  the  lower 
extremities  must  be  put  down  as  the  most  common 
non-specific  cause  of  ulcers. 

The  treatment  of  ulcers  must  be  directed  to  the 
cause  of  the  tissue  destruction.  In  varicosities  the  in- 
tegi-ity  of  the  circulation  should  be  restored  by  sup- 
porting the  vessels  by  mechanical  means,  or  relieving 
the  overpressure  by  position.  For  the  former  the  elas- 
tic stocking,  properly  adjusted,  is  invaluable.  Mar- 
tin's elastic  bandage  is  an  excellent  apparatus,  but  re- 
quires considerable  care  in  its  even  and  skillful  appli- 
cation. "When  neither  of  these  methods  is  available, 
j)ressure  may  be  successfully  employed  by  means  of 
flannel  or  muslin  bandages.  An  elevated  position  of 
the  foot  and  leg  should  be  maintained  in  all  ulcers  of 
the  lower  extremities. 

An  indolent  ulcer  demands  stimulation.  This  may 
be  effected  by  the  oakum-dressing.  Soft,  clean  oakum 
should  be  well  soaked  in  1  to  3,000  sublimate,  squeezed 
out,  laid  over  the  ulcer,  and  held  well  in  place  by  a 
roller.  It  should  be  changed  every  three  or  four  days. 
SubUmate  gauze  is  also  an  efficient  stimulating  dress- 


100  "        A  TEXT-BOOK   ON  SURGERY. 

ing.  Either  of  these  methods  should  take  the  place  of  the  old  practice 
of  burning  such  ulcers  with  escharotics.  Supporting  the  edges  of  the 
sore  with  well-adjusted  strips  of  diachylon  plaster  is  also  a  commendable 
practice.  The  strips  should  be  cut  about  three  fourths  of  an  inch  wide, 
and  crossed  in  a  spiral  manner  (Fig.  153). 

Irritable  ulcers  i-equire  rest  and  soothing  applications.  lodoform- 
vaseline  ointment  ( 3  J  to  3  j)  will  be  found  of  value.  It  should  be  applied 
on  soft  canton-flannel  or  lint,  and  not  strapped  down  tightly.  The  con- 
stitutional treatment  of  aU  j)atients  suffering  from  ulcers  is  of  first  im- 
portance. 

Gangrene  is  death  of  a  part  of  the  body  from  the  gradual  or  sudden 
arrest  of  its  nutrition.  It  is  usually  applied  to  the  process  of  mortifica- 
tion in  the  softer  structures.  The  analogous  condition  of  bone  is  called 
necrosis.  Animal  tissues  have  two  modes  of  dying — the  one  is  molecu- 
lar, or  death  by  granular  metamorphosis,  in  which  no  trace  of  the  ana- 
tomical or  histological  properties  of  the  tissues  remains ;  the  other  is 
death  in  hulk,  in  which,  although  the  tissues  deprived  of  life  undergo 
rapid  decomposition  and  ultimate  disintegration,  they  retain  for  a  time 
something  of  their  original  form.  It  is  to  denote  this  last  variety  of  tis- 
sue-death that  the  term  gangrene  is  employed. 

There  are  three- varieties — namely,  the  acute,  ov  moist;  the  cTironic, 
senile,  or  dry ;  and  the  contagious,  phagedenic,  or  hospital  gangrene. 

Acute  Gangrene. — The  chief  cause  of  moist  gangrene  is  the  sudden 
obstruction  of  the  afferent  or  efferent  vessels  of  a  part.  AVhether  the 
artery  is  alone  occluded,  as  by  an  embolus,  the  ligature,  or  an  accidental 
solution  of  its  continuity ;  or  whether  the  venous  current  is  arrested 
while  the  artery  is  permeable  ;  or  whether  the  arrest  in  both  systems  is 
simultaneous,  as  by  the  constriction  of  a  finger  with  a  ring,  or  in  the  case 
of  a  strangulated  hernia — the  part  beyond  the  lesion  is  charged  with. 
blood  which,  arrested  in  its  flow,  loses  its  vitality  and  takes  an  early  part 
in  the  work  of  decomposition  which  ensues. 

When  an  arte?"//  is  obliterated,  the  vitality  of  the  tissues  on  the  periph- 
eral side  of  the  occlusion  depends  upon  the  integrity  of  the  collateral  cir- 
culation. If  the  occlusion  is  gradual,  the  enlargement  of  the  collateral 
branches  is  usually  sufficient  to  carry  the  necessary  supply  of  blood. 
There  is  scarcely  a  point  in  the  arterial  system  where  a  collateral  route 
may  not  be  established,  provided  the  process  of  obliteration  is  not 
too  sudden,  and  the  blood  has  not,  by  I'eason  of  constitutional  dis- 
turbance, been  deprived  of  its  nutritive  properties.  When  these  condi- 
tions do  not  prevail,  mortification  ensues  with  a  rapidity  proportionate 
to  the  partial  or  total  arrest  of  nutrition.  Pallor  is  the  immediate  and 
earliest  symptom  of  arterial  obstruction,  followed  by  coldness  of  the 
skin,  and  pain,  which  is  usually  not  acute.  Beginning  in  the  parts 
farthest  removed  from  the  heart,  the  phenomena  of  death  extend  toward 
the  center  until  the  border-line  is  reached  between  the  living  and  dying 
tissues.  Congestion  and  swelling  are  not  marked  features  of  arterial 
gangrene.  The  normal  contractility  of  the  tissues,  an  elevated  position, 
and  the  influence  of  the  return  current  in  veins  with  which  those  of  the 


GAXGREXE.  Inl 

part  involved  communicate,  tend  to  empty  the  vessels  beyond  the  seat 
of  obstruction.  Of  necessity,  however,  a  considerable  quantity  of  blood 
remains,  and  when  its  flow  is  arrested  its  function  is  lost,  and  its  elements 
join  in  the  general  decomposition  v.hich  ensues.  In  the  putrefactive 
process,  gases,  notably  sulphuretted  hydrogen  and  those  resulting  from 
decomposition  of  the  fatty  tissue,  are  evolved,  and  the  coloring-matter  of 
the  blood  is  liberated.  Myosin,  the  albuminous  principle  of  muscle, 
coagulates,  giving  a  temporary  sense  of  rigidity,  and  the  serum  which 
remained  in  the  vessels  undergoes  transudation,  and  is  generally  dis- 
tributed among  the  tissues.  Cutaneous  sensibility  is  soon  lost,  and  the 
momentary  pallor  gives  way  to  a  grayish  hue,  which  deepens  into  a 
greenish- black  color.  Though  not  so  marked  as  in  the  condition  result- 
ing from  venous  occlusion,  the  skin  and  subcutaneous  tissiies  become 
infiltrated  with  fluid  and  gases,  giving  a  doughy  feel  upon  pressure,  and 
at  times  the  peculiar  crackling  of  emphysema.  Serum  and  hydrogen,  in 
the  effort  to  escape,  may  at  various  points  be  caught  under  the  imper- 
vious epidermis,  which  is  lifted  up  into  blisters.  In  resisting  gangrene, 
certain  tissues  retain  their  anatomical  features  longer  than  others.  Bone 
and  tendon  are  slow  to  disappear,  and  at  times  the  arteries  will  resist 
desti'uctive  change,  when  the  tissues  through  which  they  pass  have  been 
entirely  destroyed. 

In  a  case  which  recently  came  under  my  observation,  through  the 
courtesy  of  Prof.  Fluhrer,  at  Mount  Sinai  Hospital,  in  which  gangrene 
was  induced  by  a  plaster-of-Paris  dressing  (applied  in  another  institia- 
tion  for  supposed  fracture  of  the  humerus),  mortification  was  present 
first  in  the  thumb  and  the  tip  of  the  index-finger,  gradually  involving 
the  other  fingers  and  the  back  of  the  hand  to  the  carpus,  where  the  pro- 
cess seemed  arrested  in  an  aijparent  line  of  demarkation  in  the  integu- 
ment. The  gangrene  continued,  however,  beneath  the  skin,  involving 
the  extensor  muscles,  which,  after  amputation  above  the  elbow,  were 
found  to  have  entirely  disappeared,  while  much  of  the  integument  over 
them  retained  its  vitalitv".  When  once  inaugurated,  mortification  extends 
to  a  point  where  nutritive  changes  in  the  tissues  are  sufliciently  active  to 
resist  death.  The  irritation  of  the  dead  tissues  produces  inflammation 
and  the  formation  of  a  zone  of  embryonic  tissue  between  the  living  and 
dead  structui'es.  The  line  between  this  embryonic  zone  and  the  black- 
ened slough  is  called  the  line  of  demar'kation. 

The  line  of  demarkation  is,  as  a  rule,  irregular  in  extent.  When  a 
part  has  been  constricted  until  death  ensues,  the  line  of  separation  may 
be  a  well-defined  circumference ;  but  in  arterial  occlusion  this  is  a  rare 
exception. 

FoUowing  the  phenomena  above  detailed,  rapid  putrefactive  changes 
occur ;  the  soft  parts  drop  away  in  offensive  sloughs,  leaving  the  bone 
projecting  from  the  stump  of  this  natural  amputation. 

The  symptoms  of  gangrene  from  Tenons  obstruction  differ  in  some 
essential  features  from  mortification  after  arterial  occlusion. 

Engorgement  is  more  marked,  since  the  cardiac  and  arterial  forces  are 
at  work  in  ];)acking  the  tissues  beyond  the  obstruction  with  blood.     The 


102  A  TEXT-BOOK   ON  SURGERY. 

skin  is  of  a  purplisli  hue  from  the  start,  pain  is  intense,  and  the  swelling 
great,  and,  nntil  coag^^lation  is  accomplished,  there  is  a  sense  of  throb- 
bing in  the  affected  part.  There  is  at  first  an  elevation  of  temperature, 
which,  however,  is  of  short  duration.  Blisters  are  more  numerous,  and 
putrefaction  occurs  more  raj^idly. 

Gangrene  from  combined  arterial  and  venous  occlusion  has  its  type 
in  a  strangulated  hernia,  or  in  mortification  of  a  finger  which  has  been 
constricted  by  a  ring.  In  this  variety,  arrest  of  the  circulation  and  co- 
agulation of  the  blood  are  more  abruj)t.  The  remaining  features  of 
this  form  of  mortification  do  not  differ  materially  from  those  heretofore 
described. 

Treatment  of  Moist  Gangrene. — When  an  artery  is  obstructed,  the 
first  indication  is  to  remove  the  obstruction.  Failing  in  this,  to  promote 
the  establishment  of  a  collateral  cii'culation,  and  to  maintain  the  tempera- 
ture of  the  part  affected.  The  position  of  the  limb  should  be  such  that 
pressure  upon  the  structures  through  which  the  anastomotic  branches 
run  should  be  avoided.  Cotton-batting  should  be  carefully  wrapped 
about  the  part  to  the  thickness  of  several  inches,  and  oil-sijk  or  rubber- 
tissue  protective  wrapped  around  this.  No  pressure  by  bandages  should 
be  employed.  The  application  of  hot  water,  directly  or  by  bottles,  is 
to  be  deprecated,  for  heat  is  now  known  to  produce  capillary  contraction. 
The  extremity  may  be  slightly  lowered,  in  order  to  invite  the  flow  of 
blood,  although  care  should  be  taken  to  prevent  obstruction  of  the  veins. 

While  these  local  measures  are  being  adopted,  certain  constitutional 
remedies  may  be  indicated.  These  relate  primarily  to  cardiac  stimula- 
tion, opium  to  relieve  pain  and  palliate  shock,  and  to  an  early  improve- 
ment in  the  nutritive  quality  of  the  blood  ;  the  administration  of  alcohol 
and  beef -juice,  and  the  careful  combination  of  those  articles  of  food  which 
are  acceptable  to  the  patient,  and  are  known  to  be  rich  in  nitrogen.  Any 
intercurrent  disease  or  complication  will  indicate  a  modification  of  the 
treatment  to  suit  the  emergency.  As  death  progresses  and  the  sloughing 
begins,  all  structures  which  can  be  removed  easily  and  without  pain 
should  be  cut  away  with  dressing  forceps  and  scissors.  Iodoform,  freely 
sprinkled  over  the  sloughs,  will  prove  a  good  deodorizer,  or  the  dead  part 
may  be  kept  wrapped  in  sublimate  gauze,  soaked  in  1  to  500  solution, 
and  kept  moist  by  protective.  When  the  line  of  demarkation  is  formed, 
sublimate  gauze  (1  to  1,000)  may  be  laid  around  this  locality,  to  guard 
against  septic  absorption. 

Hgemorrhage  is  rare  in  this  variety  of  gangrene,  yet  when  it  does  occur 
it  demands  the  ligature  or  compression. 

The  treatment  of  gangrene  where  the  vein  alone  is  obstructed,  in 
which,  as  has  been  stated,  the  condition  of  engorgement  is  extreme, 
demands  the  elevation  of  the  part  in  order  to  facilitate  the  escape  of 
blood  through  the  venous  channels.  The  tension  of  the  part  may  at 
times  demand  incisions  through  the  deep  fascia.  The  same  precautions 
as  to  temperature  must  be  taken  here.  The  constitutional  treatment  will 
be  less  stimulating,  yet  supporting,  and  the  local  management  of  the 
dead  part  will  be  the  same  as  given. 


GANGRENE.  103 

When  all  the  vessels  are  subjected  to  pressure,  it  is  essential  to  relieve 
the  constriction  as  early  as  possible.  However,  the  vitality  of  an  organ 
seemingly  dead  shoiild  not  be  despaired  of,  since  restoration  of  function 
after  prolonged  strangulation  is  occasionally  witnessed.  When,  as  in 
phlegmonous  or  other  inflammation,  the  tension  is  so  extreme  that  gan- 
grene is  threatened  by  pressure  of  the  exudation  upon  the  capillaries  or 
larger  vessels,  free  incisions  should  be  made,  parallel  with  the  general 
direction  of  the  vessels,  and  of  sufficient  depth  and  number  to  relieve  the 
tension.  When,  as  in  threatened  gangrene  of  a  finger,  the  swelling  is 
severe,  increasing,  as  it  does,  the  tension  of  the  organ  and  its  own  destruc- 
tion, incisions  are  also  demanded,  and  may  prevent  mortification  before 
the  constricting  body  is  removed. 

Chronic,  Senile,  or  Dry  Gangrene. — Dry  gangrene  may  occur  in  any 
period  of  life.  Although  children  and  adults  are  occasionally  attacked, 
it  is  in  the  vast  majority  of  cases  a  disease  of  the  aged  ;  hence  it  is  called 
senile  gangrene. 

Calcareous  degeneration  of  the  arteries,  which  is  given  as  a  cause  of 
senile  gangrene,  is  of  itself  a  result  of  general  impairment  of  nutrition  ; 
and  it  is  to  this  failure  of  the  heart  to  force  the  proper  quantity  and 
quality  of  blood  to  the  tissues  that  we  must  look  for  the  cause  of  this 
disease. 

With  a  circulating  fluid  so  deficient  in  nutrition,  and  a  heart  so 
crippled  in  its  action  that  its  function  is  illy  performed,  it  is  not  difficult 
to  understand  that  the  pressure  of  a  shoe,  a  contusion  of  the  foot,  or  the 
lodgment  of  atheromatous  or  calcareous  particles  in  the  terminal  arte- 
rioles or  capillaries,  would  precipitate  a  morbid  process,  scarcely  awaiting 
even  an  accident  for  its  inauguration. 

Syviptoms. — In  many  cases  of  dry  gangrene  there  is  no  history  of  an 
injury.  Symptoms  of  constitutional  debility  from  general  impairment 
of  nutrition  usually  precede  the  local  expression  of  the  disease.  The 
lower  extremities  are  most  frequently  affected.  The  patient  sufl'ers  at 
times  from  coldness  of  the  hands  and  feet.  Shooting  pains  are  not  infre- 
quently felt,  and  cramps  occur  in  the  muscles  of  the  feet  and  calf  of  the 
leg.  In  exceptional  cases  there  are  none  of  the  above  premonitory  symp- 
toms, the  first  indication  being  the  ajjpearance  of  a  brown  or  black  dis- 
coloration on  the  foot  or  toe,  or  an  insignificant  excoriation  may  be  the 
starting-point  of  the  morbid  process. 

From  this  the  disease  travels  in  the  direction  of  the  heart  with  vary- 
ing rapidity.  If  the  condition  of  angemia  is  extreme,  there  will  be  no 
inflammatory  discoloration  in  front  of  the  advancing  line  of  mortification, 
the  skin  changing  from  its  normal  pale  color  into  the  black,  dead  hue  of 
the  miimmified  part.  The  putrescent  odor  of  wet  gangrene  is  absent, 
and,  instead  of  the  swollen,  doughy  appearance  of  acute  mortification, 
the  part  involved  becomes  hard  and  shriveled.  The  march  of  the  disease 
is  comparatively  slow,  and  not  infrequently  death  from  exhaustion 
ensues  before  the  line  of  demarkation  is  formed.  In  exceptional  instances 
the  disease  confines  itself  to  the  toes,  or  anterior  part  of  the  foot. 

Treatment. — The  part  affected  should  at  once  be  enveloped  in  cotton- 


104  A  TEXT-BOOK  ON  SURGERY. 

batting  and  oil-silk  or  protective,  and  placed  in  a  position  consistent  with 
the  comfort  of  the  patient.  No  operative  procedure  is  justifiable  until  a 
well-defined  line  of  demarkation  is  established,  unless  septic  absorption 
occnrs  to  threaten  the  safety  of  the  patient.  The  most  important  treat- 
ment is  directed  to  the  nutrition  of  the  individual  and  the  increased 
vigor  of  the  heart.  Opium,  to  relieve  pain,  is  as  much  of  a  necessity  as 
stimulants  and  food. 

Contagious,  Phagedenic,  or  Hospital  Gangrene. — Although  this  dis- 
ease occurs  most  frequently  in  hospitals  crowded  with  wounded,  where 
ventilation  and  drainage  are  deficient,  instances  are  recorded  of  outbreaks 
where  the  most  careful  sanitary  regulations  had  been  enforced.  No 
season  of  the  year  offers  an  immunity  from  its  ravages,  although  a  warm, 
moist  atmosphere  is  most  favorable  to  its  development.  It  is  intensely 
contagious.  The  inoculation  may  be  effected  not  only  through  instru- 
ments, sponges,  dressings,  or  the  hands  of  the  attendants,  bnt  through 
the  medium  of  the  atmosphere.  As  to  its  infectious  character  there 
exists  a  difference  of  opinion.  It  is  held  by  observers  equally  competent 
and  experienced  that  an  abrasion  is  essential  to  the  introduction  of  the 
disease,  and,  on  the  other  hand,  that  it  may  result  from  inhalation  of  the 
germs,  the  vesicle  and  ulcer  appearing  as  a  local  expression  of  the  sys- 
temic infection.  The  epidemics  of  phagedenic  gangrene  may  vary  in 
severity.  Appearing  in  a  malignant  form,  it  suffers  no  wound  to  escape, 
while  less  frequently  only  isolated  cases  may  occur.  While  a  healthy 
condition  of  the  individual  will  favor  a  recovery  from  the  effects  of  this 
malady,  it  affords  no  exemption  from  its  inoculation  upon  the  wounded 
surface.  It  may  be  ingrafted  upon  any  form  of  abrasion,  at  any  stage  in 
the  process  of  repair. 

Symptoms. — The  effects  of  this  disease  may  be  studied  as  local  and 
constitutional. 

When  a  recent  puncture,  or  fresh  and  minute  abrasion,  is  attacked, 
the  first  symptoms  are  the  formation  of  a  vesicle  and  the  appearance  of  a 
limited  zone  of  redness  at  its  base.  The  rupture  of  the  vesicle  gives 
escape  to  a  thin,  serous  fluid,  and  the  excoriated  base  becomes  covered 
with  a  grayish  mold.  The  infected  part  becomes  painful  and  swollen, 
and,  if  the  disease  is  not  immediately  arrested  in  its  progress,  a  rapid 
dissolution  of  the  tissues  ensues.  The  skin  breaks  down,  leaving  pre- 
cipitous margins  to  the  diseased  area.  The  underlying  tissues  are 
destroyed  more  rapidly  than  the  integument,  which  frequently  becomes 
undermined  to  such  an  extent  that,  if  repeated  careful  explorations  are 
not  made,  the  true  condition  of  the  part  may  escape  observation. 

If  at  the  time  of  inoculation  the  wound  is  covered  with  a  granulating 
surface,  it  will  be  observed  that  at  various  points  the  granulation-tissue 
loses  its  florid  color,  becomes  pale,  and  this  pallor  is  immediately  followed 
by  the  appearance  of  a  grayish-black  mold,  which  rapidly  spreads  over 
the  entire  wound.  The  normal  secretion  gives  way  to  a  dirty,  watery 
discharge.  The  odor  emanating  from  the  gangrenous  sore  is  exceedingly 
offensive  and  peculiar. 

The  constitutional  symptoms  are  those  of  acute  septicaemia,  and  are 


GANGRENE.  105 

wholly  dependent  upon  the  absorption  of  poisonous  material  at  the  seat 
of  the  disease — headache,  pain  in  the  part  aifected,  irregular  febrile 
movement,  hectic  suffusion,  followed  by  cold  perspiration,  rapid  and 
weak  pulse,  and,  as  the  malady  progresses,  great  prostration,  diar- 
rhoea, delirium,  and  death,  which  results  usually  in  from  one  to  three 
weeks. 

Prognosis. — Once  the  dread  and  scourge  of  civil  as  well  as  military 
hospitals,  contagious  gangrene,  in  the  achievement  of  modern  surgery, 
has  taken  its  place  as  a  complication  of  a  wound  annoying  and  pain- 
ful rather  than  dangerous  to  the  life  of  the  individual.  A  fatal  termina- 
tion may  ensue  when  the  wound  is  contiguous  to  important  vessels, 
where  hgemorrliage  may  occur,  either  from  death  of  the  tissues  from 
gangrene,  or  their  destruction  by  caustics  in  the  eifort  to  arrest  the  dis- 
ease. The  prognosis  may  also  be  grave  when,  from  the  nature  of  the 
injury,  the  deeper  portions  of  the  slough  can  not  be  reached,  and  drain- 
age secured.  Under  such  conditions  death  is  apt  to  ensue  from  septic 
absorption. 

Treatment. — In  the  perfect  application  of  aseptic  methods  it  is  not 
possible  for  hospital  gangrene  to  occur.  The  prophylactic  treatment  is 
the  investment  of  all  wounds  with  sublimate  or  other  aseptic  gauze 
dressings.  As  soon  as  a  wound  is  attacked  with  gangrene  it  should 
be  mopped  with  pure  bromine  or  undiluted  nitric  acid.  Care  should  be 
taken  not  to  allow  the  escharotic  to  run  over  and  burn  the  uninvaded 
skin.  If  the  neighboring  integument  is  protected  with  vaseline  this  acci- 
dent may  be  prevented.  If  the  disease  has  been  in  progress  for  one  or 
two  days,  and  the  wound  is  covered  in  with  the  pulpy  mold  peculiar  to 
this  malady,  the  entire  wound  should  be  scraped  out  with  a  Volkmann's 
spoon,  and  the  acid  or  bromine  thoroughly  applied.  When  the  skin 
has  been  undermined,  or  the  deeper  tissues,  as  the  muscles,  involved,  free 
incisions  should  be  made  in  order  to  expose  every  portion  of  the  diseased 
tissue  to  the  action  of  the  caustic.  After  this  a  plug  of  iodoform  gauze 
should  be  laid  in  the  bottom  of  the  wound,  and  a  pile  of  loose  sublimate 
gauze  (1  to  1,000)  added  to  this.  Where  a  penetrating  wound,  as  a  bullet 
or  puncture,  has  become  infected  under  conditions  that  will  not  permit 
incision,  the  entire  track  of  wounded  tissue  must  be  subjected  to  the 
process  of  cauterization  and  disinfection.  In  order  to  accomplish  this, 
the  opening  or  openings  of  the  wound  may  be  enlarged,  the  cavity  scraped 
thoroughly  with  sponges  fastened  to  holders,  and  then  the  entire  track 
inundated  with  bromine.  Ether  should  be  administered  to  relieve  the 
pain  of  the  applications,  and  opium  afterward. 

The  constitutional  treatment  looks  to  the  nourishment  of  the  patient. 
Stimulants  are  indicated,  and,  in  order  to  facilitate  prompt  assimila- 
tion, peptonized  foods  are  of  great  value.  In  this,  as  in  other  diseases 
where  it  is  essential  to  increase  the  general  nutrition  by  artificial  means, 
I  have  found  the  following  method  of  administration  invaluable  : 

On  one  day,  three  times  in  twenty-four  hours,  one  tablespoonful  of  a 
fifty-per-cent.  emulsion  of  cod-liver  oil,  the  dose  to  contain  one  grain 
each  of  hypophosphite  of  lime  and  soda.     On  the  second  day,  thirty 


106  A  TEXT-BOOK   ON  SUEGERY. 

to  forty  minims  of  the  elixir  of  iron,  quinine,  and  strychnine ;  and  on 
the  third  day,  one  tablespoonful  of  Wyeth's  beef,  iron,  and  wine. 
Alternating  in  this  manner,  these  remedies  are  tolerated  for  a  longer 
time  and  produce  a  better  result  than  when  one  article  is  administered 
day  after  day. 

The  sanitary  management  of  a  case  is  of  the  greatest  importance. 
Isolation  of  the  cases  attacked,  and  the  immediate  removal  of  other 
patients  from  the  same  ward,  tent,  or  locality,  is  urgent.  All  instru- 
ments should  be  disinfected  in  10-per-cent  carbolic-acid  solution,  or 
boiled  for  one  hour,  and  all  sponges,  dressings,  etc.,  instantly  burned. 
The  floor,  walls,  and  ceiling  of  a  hospital- ward  in  which  a  case  of  phage- 
denic gangrene  has  occurred  should  be  washed  and  irrigated  with  1  to 
1,000  sublimate  solution,  and  the  mattresses  burned. 


CHAPTER  VIIL 

AMPUTATIONS. 

Aw  amputation  is  the  complete  separation  of  any  projecting  organ  or 
member  from  tlie  body.  While  the  term  may  be  applied  to  operations 
in  which  the  breast,  penis,  scrotum,  cervix  uteri,  etc.,  are  cut  away,  by 
long  usage  and  common  consent  it  is  now  restricted  to  removal  of  the 
extremities  or  their  subdivisions. 

An  amputation  may  be  accidental^  as  when  a  limb  is  torn,  cut,  or 
crushed  off  by  machinery  ;  natural^  when,  as  in  senile  gangrene  from 
gradual  failure  of  the  heart,  or  pathological  changes  in  the  arteries,  the 
dead  portion  is  separated  at  the  line  of  demarkation  ;  or  surgical,  when 
scientifically  performed. 

When  in  an  amputation  the  line  of  section  is  through  the  substance 
of  the  bone,  the  operation  is  said  to  be  in  continuity,  and  when  through 
an  articulation,  in  contiguity.  The  removal  of  a  part  which  is  useless  or 
deformed,  the  presence  of  which,  however,  does  not  threaten  the  life  of 
the  individual,  is  called  an  amputation  of  expediency  ;  under  more  urgent 
conditions,  the  operation  is  one  of  necessity.  Amputations  of  necessity 
are  further  subdivided  into  those  after  accident  and  those  after  disease. 

In  amputations  after  accident,  the  period  in  which  the  oi^eration  may 
be  performed  is  divided  into  the  immediate,  primary,  and  secondary. 
An  immediate  amputation  is  done  during  the  prevalence  of  shock,  and 
usually  within  from  two  to  six  hours  after  the  receipt  of  the  injury  neces- 
sitating the  operation  ;  primary,  after  reaction  from  shock,  and  before 
inflammation  is  established — usually  within  twenty-four  hours  after  the 
injury  ;  secondary,  when  performed  after  this  limit,  and  during  the  preva- 
lence of  inflammation. 

The  danger  of  death  after  amputation  depends  chiefly  upon  the 
character  of  the  injury,  and  the  location  of  the  line  of  section.  The 
prognosis  becomes  grave  in  proportion  to  the  exhaustion  of  the  patient 
as  a  result  of  hgemorrhage,  shock,  sepsis,  or  of  any  dyscrasia-  or  inter- 
current disease. 

As  to  the  line  of  section,  there  are  practically  no  exceptions  to  the 
law  that  the  rate  of  mortality  is  proportionate  to  the  diameter  of  the  part 
divided  and  the  proximity  of  the  section  to  the  trunk.  Thus,  amputa- 
tions of  the  lower  extremity  are  more  fatal  than  those  of  the  upper,  those 
of  the  hip  more  fatal  than  through  the  middle  and  lower  third  or  through 
the  leg,  while  the  same  comparison  holds  good  from  the  shoulder  out. 


108  A  TEXT-BOOK   ON  SURGERY. 

As  to  the  age  of  tlie  patient,  it  may  be  said  that  the  death-rate  gradu- 
ally increases  with  each  decade  of  life. 

Operations  of  expediency,  when  properly  performed,  may  be  consid- 
ered as  practically  free  from  danger,  for  the  reasons  that  the  general  con- 
dition of  the  patient  is  good,  and  the  section  through  clean  and  healthy 
tissues.  Amputations  after  non-malignant  disease,  such  as  destructive 
arthritis  and  osteitis,  are  comparatively  free  from  danger,  provided  that 
general  sepsis  and  consequent  exhaustion  have  not  occurred  prior  to  the 
operation.  Amputations  necessitated  by  malignant  neoplasms  are  espe- 
cially dangerous  only  in  proportion  to  the  degree  of  malignancy  in  the 
tumor,  together  with  the  general  deterioration  of  the  tissues  as  a  I'esult  of 
the  prevailing  cachexia. 

Amputations  after  accident  are  most  fatal,  and  the  statistics  show  that 
primary  operations  are,  in  general,  more  dangerous  than  those  done  in 
the  secondary  period. 

Lastly,  the  value  of  the  bloodless  operation,  together  with  the  safety 
from  inflammation  and  sepsis,  which  a  thorough  knowledge  and  prac- 
tice of  the  antiseptic  method  guarantees,  can  not  be  overestimated  in 
diminishing  the  death-rate  after  amputation.  The  employment  of  Es- 
march's  bandage,  the  deligation  of  the  vessels,  the  use  of  sublimate 
irrigation,  and  the  permanent  antiseptic  dressings,  have  been  heretofore 
described. 

Amputations  are  much  less  frequent  now  than  formerly,  and  there  is 
little  doubt  that,  in  the  present  rajud' advance  in  the  science  of  surgery, 
and  the  greater  perfection  in  its  art,  the  time  is  not  far  removed  when 
amputations  for  other  cause  than  gangrene  will  be  comparatively  rare. 
To  the  consummation  of  this  hope  the  education  of  the  laity  becomes  the 
first  duty  of  the  practitioner.  Very  few  deformities  would  lead  to  the 
necessity  of  amputation  if  in  their  incipiency  the  services  of  a  skillful 
surgeon  were  obtained.  And  this  is  equally  true  of  those  lesions  of  the 
joints  and  bones  for  which  the  necessity  of  amputation  would  be  excep- 
tional if,  at  the  earliest  symptoms  of  disease,  the  proper  treatment  were 
instituted.  Even  when,  from  neglect,  extensive  necrosis  or  destructive 
arthritis  shall  have  occurred,  exsections  of  the  diseased  tissues  should 
always  be  preferred  to  amputation,  notwithstanding  the  shortening  which 
may  result,  for  a  stiff  joint  and  a  short  limb,  capable  of  even  limited 
motion  and  body  support  or  function,  is  far  better  than  the  most  perfect 
prothetic  apparatus. 

Malignant  or  non-malignant  neoplasms  often  unnecessarily  lead  to 
amputation  when  an  early  and  wide  excision  of  the  growth  would  in 
great  probability  have  arrested  the  disease  and  saved  the  limb.  In  cases 
even  of  doubtful  diagnosis,  in  the  earlier  days  of  the  appearance  of  the 
tumor,  the  benefit  of  the  doubt  should  be  given  to  the  ultimate  safety  of 
the  part,  and  the  knife  fi'eely  iised. 

As  to  the  propriety  of  performing  an  immediate  amputation  after  in- 
jury, it  is  exceedingly  questionable.  The  conditions  which  would  justify 
this  practice  will  rarely  prevail.  Even  primary  operations  should  be 
exceptional  in  this  age  when  the  value  of  drainage  is  so  fully  appreciated, 


AMPUTATIONS.  109 

and  the  danger  of  sepsis  diminislied  by  the  faithful  employment  of  that 
cleanliness  which  is  found  in  the  antiseptic  method. 

In  extensive  lacerations  of  the  soft  parts  and  fracture  of  bone,  the 
indications  in  treatment  entitled  to  the  first  consideration  may  be  stated 
as  being :  arrest  of  haemorrhage  by  the  catgut  ligature  or  direct  pressure, 
through  di-ainage,  iodoform  and  sublimate  dressings,  fixation  of  the  part 
— usually  in  an  elevated  swing  (Pigs.  7,  114,  164) — with  constant  irriga- 
tion as  a  last  resort.  If,  despite  all  these  precautions,  septicaemia  should 
occur,  or  gangrene  result,  amputation  is  necessitated. 

The  first  general  law  in  performing  an  amputation  is  that  no  more  of 
the  member  should  be  cut  away  than  is  absolutely  essential  to  the  safety 
of  the  patient.  Any  exception  to  this  rule  will  be  given  along  with  the 
special  amputation  to  which  it  may  apply. 

While  it  is  always  desii-able  to  make  an  amputation  wound  through 
healthy  tissues,  this  should  not  be  done  at  the  expense  of  the  part  in- 
volved, for  flaps  made  through  inflamed  tissues  heal  readily  enough,  and 
ofl'er  no  element  of  danger  to  the  life  of  the  patient  when  properly  drained. 

Method  of  Operating. — In  making  an  amputation,  no  matter  what 
shape  the  incisions  may  take,  the  point  of  first  importance  is,  that  the 
soft  parts  which  are  to  form  the  covering  or  hood  for  the  bone  shall  be 
long  enough  to  be  free  from  tension  after  the  sutures  are  adjusted  and 
the  dressing  completed.  It  is  always  wiser  to  err  on  the  safe  side,  and 
make  the  flaj^s  a  little  too  long  than  too  short,  for  it  is  a  simple  matter  to 
trim  them  down  to  the  proper  length.  In  doing  this,  some  allowance 
must  always  be  made  for  the  additional  retraction  which  occurs  after  the 
tourniquet  is  removed  and  consciousness  is  restored. 

The  direction  of  the  line  of  incision,  and  the  shape  of  the  cufl'  or  tiaps, 
will  depend  in  part  upon  the  shape  of  the  limb  at  the  point  of  section,  as 
well  as  the  condition  of  the  soft  tissues  from  which  the  covering  is  to  be 
made. 

While  the  rule  Just  given — namely,  to  have  plenty  of  flap — is  essen- 
tial, it  is  scarcely  of  less  importance  to  guard  against  all  interference 
with  the  nutrition  of  the  integument  which  covers  in  the  stump.  To 
this  end  rough  handling,  and  the  employment  of  strong  and  irritat- 
ing solutions,  should  be  avoided.  In  general,  that  flap  wiU  unite 
most  readily,  and  prove  most  satisfactory,  in  the  fonnation  of  which 
the  normal  relation  of  the  skin  to  the  subcutaneous  soft  tissues  is 
least  disturbed. 

It  is  always  preferable  to  divide  the  skin,  muscles,  vessels,  and  other 
soft  tissues  squarely  across,  and  not  obliquely,  as  must  of  necessity  be 
done  in  forming  flaps  by  transfixion.  The  solid-flap  method  is  applica- 
ble to  most  amputations  in  patients  of  slight  muscular  develojDment,  and 
with  little  or  no  subcutaneous  areolar  tissue,  for  a  closely  dissected  skin- 
flap  in  this  class  of  cases  is  objectionable,  on  account  of  the  danger  of 
sloughing.  When  the  soft  tissues  at  the  line  of  section  are  very  thick, 
and  when  the  integument  is  well  guarded  by  a  fair  quantity  of  under- 
lying fat,  the  solid  flap  will  be  found  objectionable,  and  flaps  composed 
of  skin  and  the  subcutaneous  tissues,  down  to  the  deep  fascia,  prefer- 


110  ^  TEXT-BOOK   ON   SURGERY. 

able.     The  circular  sTcin-Jlap,  or  some  modification  of  this  method,  will 
be  found,  in  general,  most  useful  and  satisfactory. 

The  methods  of  amputating  an  extremity  may  therefore  be :  First, 
solid  flap,  composed  of  all  the  soft  tissues  lifted  from  the  periosteum  ; 
second,  sTiin-flap,  composed  of  the  integument  and  the  subcutaneous 
tissue,  down  to  the  deej)  fascia  ;  third,  mixed  flap,  composed  of  skin  on 
one  side,  and  of  all  the  soft  tissues  on  the  other. 

Flaps  composed  of  the  integument,  together  with  all  the  underlying 
soft  tissues,  may  be  made  by  the  circular  method,  forming  a  single  cufl^, 
or  by  the  double-beveled  flap,  made  by  transfixion  and  cutting  from 
within  out,  or  by  cutting  directly  down  from  the  surface. 

Circular  Solid  Flap,  with  Perpendicular  Slit — First  MetJiod. — Sup- 
posing that  the  section  is  through  the  right  humerus,  at  the  junction  of 
the  middle  and  lower  thirds,  jDroceed  as  folloAVS :  Place  the  patient  so 
that  the  member  to  be  removed  projects  well  over  the  edge  of  the  table. 
Envelop  the  rest  of  the  body  with  necessary  wraps,  and  cover  all  in  with 
rubber  cloth,  so  arranged  that  the  irrigating  fluid  will  not  reach  any  por- 
tion but  the  arm.  If  folded  properly  into  a  trough-shape,  the  solution 
will  be  conducted  into  a  vessel  beside  the  table.  The  entire  hand  and 
arm  should  be  washed  with  soap  and  water,  cleanly  shaved  for  six  inches 
above  and  below  the  line  of  section,  and  in  succession  washed  with  sul- 
phuric ether  and  a  solution  of  corrosive  sublimate  (1  to  3,000).  If  any 
inflamed  or  sujppurating  surfaces  are  exposed,  close  to  the  line  of  am- 
putation, these  should  be  irrigated  with  sublimate,  and  thoroughly 
scraped  out  and  again  irrigated,  after  the  Esmarch  bandage  has  been 
applied.  Towels  wet  in  warm  (1  to  3,000)  sublimate  solution  are  now 
wrapped  about  the  hand,  forearm,  and  arm,  the  extremity  elevated,  in 
order  to  facilitate  gravitation  of  blood  toward  the  center,  and  the 
Esmarch  bandage  tightly  applied,  from  the  finger-tips  to  the  axilla.  As 
soon  as  the  constricting  band  is  secured  at  or  close  to  the  axilla,  the 
bandage  beyond  is  removed,  and  all  exposed  parts  not  in  the  field  of 
operation  covered  with  fresh,  warm  sxiblimate  towels.  The  assignment 
of  positions  about  the  table  are  shown  in  Fig.  154.  The  operator  stands 
so  that  the  non-preferred  hand  (usually  the  left)  grasps  the  member 
between  the  line  of  section  and  the  trunk,  and  thus  steadying  the  tissues, 
the  instruments  are  used  by  the  right  hand.  The  first  assistant  stands 
where  he  can  most  easily  reach  the  wound,  for  purposes  of  sponging, 
retracting  flaps,  etc.  ;  the  second  is  placed  directly  between  the  operator 
and  the  instrument- trays ;  the  tJiird  attends  to  the  anaesthetic,  holding 
the  cone  so  that  the  expired  air  and  ether  vapor  will  not  annoy  the  opera- 
tor ;  the  fourth  holds  the  member  to  be  removed,  grasping  the  elbow  with 
his  left  hand,  and  the  wrist  and  forearm  with  the  right ;  the  fifth  attends 
to  the  irrigator  ;  the  sixth  and  seventh  are  intrusted  with  the  sponges,  one 
of  whom  holds  in  one  hand  a  basin  of  freshly  squeezed  out  sponges,  and 
in  the  other  a  second  basin  for  those  which  have  become  soiled  or  bloody. 
Both  should  be  wiihin  easy  reach  of  the  first  assistant.  The  duty  of  the 
seventh  assistant  is  chiefiy  to  rinse  the  sponges,  procure  fresh  towels,  etc. 
When  possible,  it  is  always  convenient  to  have  two  extra  orderlies  or 


AMPUTATIONS. 


Ill 


mirses — one  for  waiting  upon  tlie  angesthetizer,  and  the  other  for  purposes 
of  general  utility. 

Operation — First  Metliocl. — With  the  left  hand  slide  the  skin  toward 
the  shoulder,  and  at  a  point  sufficiently  below  the  line  of  section  through 


the  bone  to  afford  ample  covering  (something  more  than  one  half  the 
diameter  of  the  limb,  measured  where  the  saw  is  to  be  applied),  make  a 
circular  cut  around  the  member,  dividing  the  skin  and  subcutaneous  fat 
down  to  the  deep  fascia  (Fig.  155).  The  upper  margin  of  this  wound  is 
retracted  toward  the  body  as  far  as  possible, 'and,  at  this  line  of  retraction, 


Fig.  155. — Circular  incision  through  the  sMn 


with  the  same  knife  (a  good  scalpel  is  preferable)  cut  all  the  remaining 
soft  tissues  squarely  down  to  the  periosteum  (Fig.  156).  An  incision  is 
next  made,  parallel  with  the  axis  of  the  humerus,  on  the  outer  (or  non- 
vascular) side  of  the  arm,  dividing  everything  to  the  periosteum,  and 
extending  up  to  the  point  where  the  bone  is  to  be  sawn  through  (Fig. 


112 


A  TEXT-BOOK   ON  SURGERY. 


157).     Witli  a  dry  dissector  (the  handle  of  the  scalpel  will  usually  suffice) 
— only  using  a  sharp  instrument  where  necessary— lift  the  tissues  closely 


KiG.  156. — The  same,  coutiuued  down  to  the  bone. 


from  the  periosteum  until  the  solid  cuff  can  be  folded  back  (without 
over-traction  or  bruising)  sufficiently  to  expose  the  bone  at  the  point  of 


Fig.  157.— Longitudinal  incision. 


section.     A  towel  moistened  in  1  to  3,000  sublimate  (or  a  split  retractor) 
is  now  wrapped  about  the  cuff  or  flap  and  the  bone,  so  that  the  tissues 


which  compose  the  flap  may  not  be  bruised  or  torn  by  the  saw,  and  at 
the  same  time  be  protected  from  having  the  bone-dust  scattered  over 
the  cut  surface  (Fig.  158). 


AMPUTATIONS.  113 

In  applying  tlie  saw,  it  is  best  to  place  the  center  of  this  instrument 
against  the  bone  close  up  to  the  retractor,  always  holding  its  blade  in 
such  relation  to  the  bone  that  the  sawn  surface  will  be  perpendicular 
to  the  axis  of  the  bone.  A  few  short  strokes  will  suffice  to  cut  a  trench  or 
hold  for  the  saw,  which  may  then  be  more  rapidly  used.  The  operator 
steadies  the  member  with  his  left  hand  on  the  central  side  of  the  wound, 
while  the  assistant  holds  the  extremity.  As  the  section  is  about  being 
completed,  he  is  directed  to  cease  all  traction,  simply  supporting  the 
weight  of  the  limb,  and  thus  splintering  may  be  avoided.  The  last  few 
strokes  of  the  saw  should  be  lightly  and  carefully  made,  to  avoid  the  same 
accident.  The  retractor  is  allowed  to  remain  after  the  bone  is  divided 
and  the  amputated  part  removed,  and  imtil,  with  a  bone-cutter  or  carti- 
lage-knife, the  circumference  of  the  cut  surface  is  smoothed  and  rounded 
off.  In  doing  this,  the  force  applied  should  always  be  toward  the  center 
of  the  bone,  to  prevent  stripping  up  the  periosteum  or  splintering. 

The  practice  of  dissecting  a  periosteal  cuff,  at  one  time  recommended 
for  the  purpose  of  covering  over  the  end  of  the  bone,  is  now  justly 
abandoned.  While  it  succeeded  in  some  instances,  in  many  it  gave  rise 
to  great  annoyance,  necessitating  a  second  operation  on  account  of  ex- 
ostosis or  necrosis.  The  retractor  is  now  removed,  the  stump  ii-rigated, 
and  the  surface  then  thoroughly  dried  with  sponges,  so  that  the  vessels 
may  be  secured.  The  larger  arteries  and  veins  may  be  readily  found, 
and  the  ends  seized  with  the  forceps.  All  the  tissues  should  be  care- 
fully stripped  fi'om  these  by  a  blunt  instrument  (grooved  director), 
and,  when  the  catgut  is  thus  applied,  the  operator  is  sure  that  no  nerve- 
tissue  is  caught  along  with  the  vessel.  For  the  larger  vessels  the  double 
or  friction  loop  (Fig.  113)  should  be  employed  ;  the  single  knot  will  suffice 
for  the  smaller.  When  ligatures  have  been  appKed  to  all  the  vessels 
which  can  be  recognized  by  the  eye,  other  "  bleeding  points "  may  be 
discovered  by  grasping  the  limb  a  few  inches  above  the  line  of  section 
and  then  forcing  out  the  small  quantity  of  blood  which  remains  after 
Esmarch's  bandage.  As  it  oozes  oiit  over  the  cut  surface,  its  point  of 
exit  may  be  caught  up  by  the  broad-jawed  forceps,  and  in  doing  this 
it  is  usually  necessary  to  pick  up  a  small  bit  of  whatever  tissue  may 
be  immediately  about  the  vessel.  In  tying  a  catgut  thread  around 
these  vessels,  the  loop  should  be  tightened  upon  the  jaws  of  the  instru- 
ment on  the  slope  nearest  the  point,  for  as  it  is  further  tightened  it 
grasps  the  metal  closely  and  slides  over  the  end,  including  no  tissue 
but  that  already  in  the  grasp  of  the  forceps.  Having  proceeded  thus  far, 
the  stump  being  elevated,  the  wound  should  be  filled  with  clean  warm 
sponges,  covered  with  sublimate  towels,  and  firmly  compressed  by  the 
operator  while  the  assistant  removes  the  tourniquet.  After  waiting  two 
or  three  minutes  for  the  vessels  to  fUl,  one  by  one  the  sponges  are  care- 
fully removed,  and  any  bleeding  poiuts  caught  with  the  forceps.  When 
these  shall  have  been  tied,  the  wound  should  again  be  flooded  -nuth  warm 
1  to  3,000  sublimate,  packed  with  sponges  well  squeezed  out,  the  whole 
covered  in  with  sublimate  towels,  and  bimanual  compression  employed 
for  five  minutes,  when  it  will  be  seen  that  all  bleeding  has  practically 


114  A  TEXT-BOOK   ON  SURGERY. 

ceased.  The  general  oozing,  especially  tliat  from  the  end  of  the  bone, 
may  be  controlled  by  pressure  and  position  after  the  sutures  are  applied. 
In  sewing  up  the  cuff,  alternate  deep  and  superficial  sutures  should  be 
employed ;  the  former,  about  half  an  inch  apart,  should  enter  the  skin 
from  one  half  to  three  fourths  of  an  inch  from  the  edge  of  the  wound, 
pass  about  the  same  depth  through  all  the  tissues,  and  emerge  at  the 
same  distance  from  the  wound  on  the  op]3osite  side.  The  intervening 
row  should  be  half  way  between  the  deei)er  sutures,  and  should  be  intro- 
duced to  a  depth  of  one  fourth  of  an  inch.  In  tying  the  sutures  the 
double  or  friction  knot  should  be  employed  for  the  first  loop,  for  this 
holds  and  keeps  the  edges  from  separating  while  the  second  knot  is  being 
tied.  The  knots  should  be  kept  to  one  side  of  the  line  of  apposition.  A 
considerable  degree  of  care  is  essential  in  bringing  the  edges  nicely  and 
accurately  in  apposition,  for  if  the  skin  is  infolded  and  the  epidermal 
surfaces  brought  in  contact,  bad  union  will  result,  and  the  same  is  true 
if  any  of  the  subcutaneous  tissues  project  between  the  edges.  As 
the  threads  are  being  tightened,  infolding  may  be  obviated  by  lifting 
the  edges  with  a  grooved  director,  while  the  same  instrument  may  be 
employed  to  push  any  projecting  fat  or  other  tissues  back  under  the 
skin.  In  tying  the  knots,  the  degree  of  traction  should  just  be  suffi- 
cient to  bring  the  -plane  surfaces  of  the  wound  together  without  wrink- 
ling. The  drainage-tubes  should  be  inserted  as  the  wound  is  being 
closed,  and  should  be  numerous  enough  to  drain  the  cuff  at  all  points. 
In  clean  amputations  Neuber's  bone-drains  should  always  be  used.  In 
cutting  through  inflamed  or  infiltrated  tissues,  the  rubber  tubes  are  safer. 
If  (as  is  preferable)  the  stump  is  kept  elevated  after  the  operation,  it 
will  be  necessary  to  bring  at  least  one  of  the  tabes  out  at  the  upper  end 
of  the  longitudinal  incision,  while  another  may  project  at  the  tii:)  of  the 
stump.  No  matter  what  style  of  flap  is  used,  the  tubes  should  always 
lead  from  the  deepest  portion  of  the  wound,  and  have  exit  at  such 
declination  that  the  free  outflow  of  all  fluids  will  take  place  into  the  dress- 
ings. A  safety-pin  should  be  passed  through  one  side  of  the  tube  to 
prevent  its  being  pressed  into  the  wound  by  the  bandaging,  or  a  suture 
may  serve  to  hold  it  in  position.  The  nozzle  of  the  irrigator  should  now 
be  introduced  into  one  of  the  tubes  and  the  cuff  flooded  until  the  water 
runs  out  clear  and  until  the  entire  flap  has  been  well  distended.  The 
excess  of  the  solution  is  squeezed  out,  a  strip  of  iodoformized  gauze  is 
wound  around  the  tubes  (not  obstructing  their  caliber),  and  carried  along 
the  line  of  approximation,  extending  about  three  fourths  of  an  inch  on 
either  side.  Or  a  narrow  piece  of  disinfected  protective  may  be  substi- 
tuted as  a  covering  for  the  line  of  sutures.  The  stump  is  now  wiped  off 
with  sponges  and  immediately  enveloped  with  sublimate  gauze  to  the 
thickness  of  about  one  inch.  This  should  be  applied  in  layers,  starting 
from  well  above  the  end  of  the  stump,  by  carrying  a  layer  around  the 
limb,  and  following  this  with  a  second,  which  overlaps  the  first  about 
two  inches,  and  so  on  until  the  last  layer  projects  well  beyond  the  end  of 
the  stump.  Over  the  end  a  large,  thick  sheet  of  gauze  is  laid.  A 
layer  of  absorbent  cotton,  about  one  inch  thick,  is  now  wrapped  around 


AMPUTATIONS. 


115 


and  over  the  end,  and  this  enveloped  by  a  large  sheet  of  rubber-tissue 
protective.  A  roller  is  carried  over  all  to  hold  the  dressing  in  place,  and 
to  make  compression  sufficient  to  arrest  oozing.  It  is  impossible  to  say  hovf 
much  pressure  should  be  employed,  since  this  knowledge  can  only  come 
from  practice,  but  the  bandage  should  be  fairly  tight.  Over-pressure  at 
the  tip  should  be  avoided,  especially  where  the  flap  folds  down  on  the 
end  of  the  bone.  As  the  last  bandage  is  being  applied,  a  short  splint, 
the  end  of  which  projects  a  couple  of  inches  beyond  the  stump,  should 
be  inserted.  This  steadies  the  limb,  and  is  useful  in  keeping  the  stump 
elevated,  especially  when  an  amputation  is  made  near  the  trunk.  If  the 
last  roller  is  made  wet  before  being  applied,  it  will  be  less  liable  to  slip. 

Such  a  dressing,  under  the  strict  antiseptic  method,  is  not  usually 
removed  before  the  tenth  or  twentieth  day,  and  in  the  majority  of  cases 
where  an  amputation  is  made  through  comjaaratively  healthy  tissues  a 
single  dressing  is  sufficient.  The  indications  for  its  removal  are  hjemor- 
rhage  of  an  alarming  nature,  great  pain,  high  febrile  movement  (not 
counting  the  reactionary  fever  which  follows  within  twenty-four  hours 
after  the  operation),  and  excessive  discharge  beyond  the  zone  of  anti- 
sepsis, with  decomposition. 

Ordinary  bleeding  may  be  controlled  and  permanently  arrested  by  an 
extra  tight  roller,  or  Esmarch  bandage,  loosely  applied  for  an  hour  or 
two.  A  rise  in  the  temperature  of  102°  to  103°  on  the  second  day,,  or 
later,  suggests  inflammation  and  sepsis.  Lastly,  when  the  serum  or  fluids 
from  the  stump  seep  under  the  dressing  and  decompose,  the  change  is 
necessitated  on  account  of  the  odor.  When  a  new  dressing  is  made,  the 
same  antiseptic  precautions  should  be  employed. 

Second  Metliod — Oblique  Solid  Fla-ps  by  Transfixion. — Seize  the  arm 
with  the  left  hand  so  that,  as  all  the  soft  tissues  are  pinched  up  on  its 
anterior  asj)ect,  the  thumb  and  index-finger  on  opposite  sides  will  be  just 
above  the  point  at  which  it  has  been  decided  to  divide  the  bone.  The 
point  of  a  long  knife  is  pushed  from  the  outer  side  (right  arm)  horizon- 
tally down  until  it  impinges  upon  the  center  of  the  bone ;  the  handle  is 
depressed,  the  point  grazes  over  the  bone,  the  handle  is  now  elevated,  and 


the  point  made  to  project  exactly  opposite  and  on  the  same  plane  with  the 
point  of  entrance  (Fig.  1.59).  By  a  long  sawing  movement  the  knife  is  made 
to  cut  directly  along  the  bone  until  wdthin  from  one  half  to  one  inch  of  the 


116  A  TEXT-BOOK   ON  SUKGERY. 

limit  of  the  flap,  wlien  it  is  turned  rather  abruptly  out,  shaping  a  blunt, 
rounded  flap.  This  is  held  back  by  the  operator's  left  hand,  the  point  of 
the  knife  is  insinuated  between  the  muscles  and  the  bone,  is  made  to 
glide  along  the  posterior  surface  of  the  bone,  and  to  come  out  at  or  very 
near  the  periosteum  on  the  opposite  side.  A  second  symmetrical  flap  is 
made  in  the  same  way  as  the  first.  The  retractor  is  applied,  and  the 
operation  and  dressing  completed  as  before. 

In  making  an  amputation  by  transfixion,  it  is  usually  advised  to  cut 
the  non-vascular  flap  first ;  but,  with  a  safe  tourniquet  applied,  this  pre- 
caution is  unnecessary. 

Third  Method — Oblique  Solid  Flaps,  hy  cutting  from  the  Surface. — 
Cutting  from  the  surface  toward  the  bone,  the  first  crescentic  incision  out- 
lines one  flap  and  goes  down  to  the  deep  fascia  (Fig.  160).    After  the  skin 


Fio.  160. — Oblique  solid  flaps,  made  by  outting  downward  from  the  skin. 


retracts,  the  muscles  and  remaining  soft  tissues  are  divided  from  its  edge 
obliquely  down  to  the  point  of  section  through  the  bone.  The  opposite 
flap  is  made  in  the  same  manner,  and  the  operation  completed  as  before. 


Skin  -  Flaps  —  Circular,  Modified  Circular,  Oval,  Double  Crescentic, 
and,  Double  Rectangular. 

First  Method — Circular. — Before  commencing  the  incision,  grasp  the 
arm  firmly  near  the  line  of  incision,  and  slide  the  integument  upward  as 
far  as  it  will  go.  In  doing  this  operation,  a  good  scalpel  is  preferable  to 
the  long  knife.  The  incision  should  go  straight  down  to  the  fascia  which 
covers  the  muscles,  and  directly  around  the  limb  by  successive  strokes  with 
the  scalpel,  so  that  the  radius  of  the  circle  described  will  be  at  an  angle  of 
90°  with  the  axis  of  the  humerus  (Fig.  161  a).  When  this  is  completed, 
catch  the  edge  of  the  flap  with  a  mouse-tooth  dissecting-forceps,  put  the 
connective  tissues  which  attach  it  to  the  fascia  about  the  muscles  on  the 
stretch  by  pulling  the  skin  upward,  and  with  well-directed  strokes  or 
touches  with  the  point  of  the  knife,  which  should  be  kept  from  wounding 
the  skin,  raise  the  flap  throughout  the  entire  circumference  of  the  wound. 
As  this  dissection  proceeds,  the  loosened  sleeve  of  integument  may  be 
rolled  up  ixntil  the  point  where  the  muscles  and  bone  are  to  be  divided  is 
reached  (Fig.  161  b).  Just  at  the  margin  of  the  reflected  flap  the  soft  tis- 
sues are  now  divided  straight  down  to  the  bone,  the  line  of  section  being 


AZ^IPUTATIOXS. 


ii: 


perpendicnlar  to  the  axis  of  the  limb.     The  periosteum  should  next  be 
cut  through  in  the  circumference  of  the  bone  where  the  saw  is  to  enter. 


Pig.  161.— (ilodilied  from  Esmarch.) 


Second  Method — Modified  Circular. — When,  on  account  of  the  large 
diameter  of  the  member,  the  flap  requires  to  be  dissected  up  for  more 
than  two  inches,  the  foregoing  method  may  be  modified  by  a  perpen- 
dicular incision  through  to  the  muscles.  This  renders  the  dissection 
more  rapid. 

Tfiird  Ilethod — Oval. — It  not  infrequently  occurs  that  the  condition 
of  the  soft  parts  near  the  line  of  amputation  will  not  permit  of  an  incision 
directly  around  the  limb  without  a  too  great  sacrifice  of  the  member. 
Under  such  cii'cumstances,  an  oval  or  elliptical  incision  may  be  made, 
and  in  this  way  integument  enough  secured  to  cover  in  the  stump.  The 
longitudinal  slit  may  be  added  to  this  operation. 

FourtTi  MetTiod — Double  Crescentic. — The  circular  operation  may  be 
fui'ther  modified  by  making  two  crescentic  skin-flaps  of  equal  size,  the 


Fig.  162.— (After  Esmarch.) 


bases  of  these  being  at  the  line  of  section  of  muscle  and  bone.  The  same 
precautions  as  given  above  are  necessary  to  secure  enough  integument 
to  form  a  hood  for  the  stump  (Fig.  162). 


1X8  A  TEXT-BOOK   ON  SURGERT. 

Fiftli  Metliod— Double  Beciangular.— The  first  step  is  to  go  around 
the  liiQb  just  as  if  a  circular  operation  were  intended.  This  being  done, 
two  incisions,  one  on  either  side  and  exactly  opposite  to  each  other,  are 
made  perpendicular  to  the  circular  cut,  and  extending  up  the  limb  to  a 
point  on  a  level  with  the  line  of  section  through  the  muscles  and  bone 
(Fig.  163).     The  two  flaps  are  now  dissected  up  to  this  line,  and  the 


amputation  completed  as  before.  The  commendable  features  of  this 
procedure  are  the  rapidity  with  which  it  may  be  accomplished,  the  small 
degree  of  violence  inflicted  in  manipulating  the  flajjs,  and  the  readiness 
with  which  a  stump  is  drained  when  the  proximal  angles  of  the  lateral 
incisions  are  used  as  outlets  for  the  tubes. 

Mixed  Flaps,  com]posed  of  integument  alone  on  one  side  and  of  all 
the  soft  tissues  on  the  other,  are  the  least  commendable  of  all  meth- 
ods. The  proper  apposition  of  surfaces  so  uneven  is  difficult.  When 
from  any  cause  this  operation  is  adojjted,  care  must  be  taken  to  give 
projier  support  to  the  heavy  solid  flap  to  prevent  dragging  upon  the 
sutures. 

Resume. — In  thin  and  emaciated  subjects  the  solid,  flaps  should  be 
preferred  to  the  skin  flaps,  for  the  reasons  that  the  nutrition  of  the  skin 
is  least  disturbed  by  this  method.  In  limbs  of  large  diameter  and  a 
goodly  quantity  of  subcutaneous  tissue,  the  skin-tiai^s  are  preferable, 
since  a  covering  under  such  conditions  can  be  obtained  with  less  sacrifice 
in  the  length  of  the  bone.  Of  the  solid  flaps,  the  circular  method  is 
better  than  the  oblique,  since  it  divides  all  the  tissues  squarely.  In 
making  oblique  flajDS,  transfixion  is  better  than  cutting  from  without 
inward.  Of  the  skin-flaps,  the  circular  incision  should  be  preferred  to 
the  other  methods  where  the  limb  is  not  very  large  ;  the  double  rectan- 
gular flaps  where  the  stump  is  to  be  elevated  and  there  is  a  large  surface 
to  drain. 

Ojoen  Method. — When  an  amputation  is  made  through  tissues  infil- 
trated with  pus  or  other  infiammatory  products,  where,  in  the  judgment 
of  the  surgeon,  the  dangei-s  of  sepsis  would  be  increased  if  the  wound 
were  closed,  the  open  method  should  be  emj)loyed,  with  constant  or  in- 
terrupted irrigation. 


AMPUTATIOXS. 


119 


Before  the  days  of  antisepsis  the  success  of  this  method  was  thor- 
oughly demonstrated  by  Prof.  James  E,.  Wood  and  Prof.  Dennis,  in 
BeUevue  Hosi^ital,  where  the  rate  of  mortality  after  amputations,  in 
wards  which  had  been  recently  vacated  on  account  of  pueriaeral  fever, 
was  reduced  to  the  minimum  in  the  history  of  that  hospital.  I  have 
employed  this  method  in  a  number  of  septic  cases  with  great  satisfaction. 


In  performing  the  amputation,  the  flaps  must  be  so  shaped  that  irriga- 
tion can  be  easily  accomplished  without  moving  the  stump.  A  cu'cular 
cut,  -with  a  longitudinal  incision  on  the  up]3er  surface,  or  bilateral  flaps, 
are  preferable.  When  the  patient  is  put  to  bed  the  stump  is  placed  in 
a  ]position  suitable  for  draraage,  and  rests  upon  an  oil-cloth  so  arranged 
that  the  irrigating  fluid  runs  away  from  the  patient  and  into  a  basin  at 
the  bedside.  The  flaps  should  at  first  be  held  well  open  by  a  wad  of 
sublimate  gauze,  and  the  stump  loosely  enveloped  in  a  thin  layer  of  this 


120  A  TEXT-BOOK  ON  SURGERY. 

material,  so  arranged  that,  as  the  water  drips  on  it,  it  will  pass  through 
the  gauze  and  over  the  raw  surface. 

Fig.  164  shows  a  ready-made  irrigator  in  use  in  my  service  at  Mount 
Sinai  Hospital.  A  piece  of  sheet-tin,  about  a  foot  vnde  and  of  any  re- 
quired length,  is  shaped  into  a  trough,  the  bottom  of  which  is  punched 
full  of  holes  with  an  awl.  A  rubber  tube  leads  the  water  from  a  tank 
into  this  trough,  from  which  it  trickles  on  to  the  wound  in  any  required 
quantity.  Or,  as  represented  in  the  cut,  the  tube — which,  in  the  case  of 
the  patient  from  whom  the  drawing  was  made,  conveyed  the  irrigating 
fluid  into  a  suppurating  knee-joint—may  also  be  employed  to  carry  the 
water  into  the  wound. 

Pure  water  should  be  used  for  irrigation.  The  danger  of  absorption 
from  an  extensive  granulating  surface  precludes  the  sublimate  or  carbolic- 
acid  sohxtions. 

The  only  objection  to  which  this  method  is  open  is  the  slowness  with 
which  the  process  of  repair  goes  on  in  its  employment.  This  is,  however, 
an  objection  of  little  weight  when  the  ultimate  recovery  of  the  patient  is 
secured.  As  soon  as  the  temperature  shows  an  absence  of  sepsis  the  irri- 
gation may  cease,  and  the  granulating  flaps  may  be  approximated  grad- 
ually by  bandages  or  adhesive  strips. 

Special  AMPUTATioisrs. 

Sand  and  Fingers. — A  primary  amputation  of  any  portion  of  the 
hand  is  rarely  justifiable.  If  there  is  only  a  small  strip  of  tissue,  the 
integrity  of  which  is  evident,  an  efl'ort  at  the  restoration  of  the  nutrition 
and  function  of  the  part  beyond  should  be  attempted.  If  any  doubt 
exists  as  to  the  result,  the  benefit  of  this  should  be  given  to  the  side  of 
conservatism.  It  is  essential  to  arrest  hgemori'hage,  cleanse  the  wounds 
under  strict  antisepsis,  and  especially  by  thorough  immersion  in  a  basin 
of  warm  sublimate  solution  (1  to  3,000),  secure  di-ainage,  and  place  the 
parts  in  the  best  position  for  usefulness  in  case  of  recovery.  Amputation 
may  be  done  when  necessitated  by  gangrene  or  necrosis. 

Fingers  —  Inter  phalangeal  Operations. — Between  the  second  and 
third  phalanges  of  the  fingers,  proceed  as  follows :  Flex  the  terminal 
phalanx  at  about  an  angle  of  90°  to  the  axis  of  the  second  bone,  and, 
one  eighth  of  a,n  inch  anterior  to  the  angle  on  the  dorsal  aspect,  with 

a  small,  sharp-pointed  scalpel  make  a 
^_----p  ■'"'" '-  "^  ■  '~~'~~~'~^~~;~—  transverse  incision,  extending  half-way 
ClcS*'^3*~=^*    ^  -       -.     V      (^Q-^yjj  ^]jQ   sides   of  the  finger.      From 

this  point  carry  the  incision  forward, 
parallel  with  the  axis  of  the  digit,  to 
within  a  quarter  of  an  inch  of  the  end, 
Fig.  165.  then  across  the  palmar  aspect  of  the  tip 

to  the  opposite  side,  finishing  the  in- 
cision at  the  angle  of  the  transverse  cut  (Fig.  165).  Dissect  the  palmar 
flap  up,  keeping  close  to  the  bone,  lifting  the  flexor  tendon,  with  the 
skin,  back  to  the  articulation  ;   divide  the  tendon  opposite  the  joint, 


AMPUTATIOXS.  121 

and  disarticulate.  Tlie  flap  is  now  turned  back,  trimmed  -n-itli  the 
scissors  to  fit  nicely,  and  stitched  with  silk  or  catgut  sutures.  By 
this  method  the  acute  tactile  sense  of  the  palmar  aspect  of  the  finger 
is  preserved,  and  adds  to  the  usefulness  of  the  stump.  This,  and  other 
amputations  of  the  fingers,  may  be  made  without  general  anaesthesia, 
and  with  perfect  insensibility,  by  the  local  use  of  cocaine.  Just  ante- 
rior to  the  metacarpo-phalangeal  joint  insert  on  each  latex'al  aspect  of  the 
finger  the  needle  of  a  hypodermic  syringe,  and  inject  in  the  entire  cir- 
cumference of  the  finger  twenty  minims  of  a  4-X3er-cent  solution  of 
cocaine  hydrochlorate.  One  minute  later  constrict  the  root  of  the  digit 
with  an  elastic  ligature.  In  this  way  a  painless  and  bloodless  operation 
may  be  performed.  If  the  insensibility  is  not  complete  at  all  points  of 
the  incision,  inject  additional  cocaine,  and  by  massage  distribute  it 
through  the  tissues. 

In  dressing  these  amputations  the  pressure  on  the  end  of  the  stump 
should  be  light,  for  fear  of  slough  in  the  long  flap.  Usually  no  vessels 
need  to  be  tied.  The  covering  of  cartilage  does  not  require  to  be  scraped 
or  sawn  ofi".  When  only  a  slight  portion  of  the  anterior  tip  of  the  second 
phalanx  is  involved  in  a  destructive  osteitis  or  injury,  the  remaining 
portion  should  not  be  sacrificed  by  a  disarticulation  at  the  posterior 
iaterphalangeal  joint.  The  line  of  section  through  the  bone  should  be 
about  at  the  junction  of  the  middle  and  anterior  third  of  the  phalanx. 
The  incisions  and  flap  are  made  as  in  the  preceding  operation. 

In  amiDutation  with  disarticulation  at  the  posterior  interiihalangeal 
joint,  flex  at  an  angle  of  90°,  make  a  transverse  incision  over  the  dorsiim 
of  the  finger,  from  one  eighth  to  one  fourth  of  an  inch  in  front  of  the 
angle,  which  includes  half  the  circumference  of  the  member.  From  the 
ends  of  this  line  carry  the  incision  directly  forward  on  each  lateral  aspect 
of  the  finger  to  the  crease  on  the  palmar  surface  opposite  the  anterior 
interphalangeal  joint.  A  second  transverse  incision  in  this  fold  com- 
pletes the  rectangular  flap,  which  is  now  dissected  back,  and  the  dis- 
articulation effected  by  placing  the  ligaments  on  the  stretch  and  divid- 
ing these  with  a  narrow,  sharji  scalpel.  If  any  difficulty  is  found 
in  entering  the  joint  from  the  sides  or  front,  it  may  be  easily  done  by 
division  of  the  extensor  tendons  over  the  dorsum,  for  these  take  the 
place  of  posterior  ligaments.  The  method  of  amputation,  as  given  for 
the  operation  at  or  near  the  articulation  of  the  first  and  second  pha- 
langes of  the  finger,  applies  also  to  the  thumb  in  amputation  at  the 
last  joint,  or  through  the  first  phalanx,  within  one  fourth  of  an  inch  of 
its  anterior  extremity.  This  plan  of  making  the  flaps  is  far  superior 
to  that  advised  by  Erichsen,  Esmarch,  and  other  authors  who  recom- 
mend cutting  down  and  through  the  joint  from  the  dorsum,  and  then 
forward  along  the  palmar  aspect  of  the  phalanx,  making  the  disarticu- 
lation and  flap  with  a  single  stroke.  In  the  first  place,  this  is  done 
with  no  little  difficulty,  for,  however  thin  the  blade,  the  character  of  the 
joint  will  scarcely  allow  an  easy  passage  to  the  knife.  Secondly,  by 
the  method  of  transfixion  the  flap  is  apt  to  be  cut  too  pointed  and  bev- 
eled at  the  end. 
9 


122 


A  TEXT-BOOK   ON   SURGERY. 


At  the  Metdcarpo-Phalangeal  Joint — Thumb. — When  the  condition 
of  the  soft  parts  will  permit,  proceed  as  follows  : 

Fii'st  Method. — Just  over  the  joint,  and  in  the  middle  of  the  dorsal 
aspect  of  the  thumb,  commence  an  incision  and  carry  it  along  the  surface 
next  to  the  index-finger  until  half  the  circumference  of  the  member  is 
included.  Along  the  dorsal  and  palmar  aspects  carry  parallel  incisions 
forward  until  near  the  interphalangeal  joint,  and  connect  these  by  a 
straight  transverse  cut  across  the  palmar  surface.  Dissect  the  flap  back, 
divide  all  tendons  opposite  the  joint,  disarticulate,  tie  the  clorsales 
poinds  (one  on  either  side  of  the  back  of  the  thumb),  and  the  arteria 
princeps  pollicis,  which  lies  along  the  side  of  the  metacarpal  bone  near- 
est the  index-finger  and  divides  into  its  terminal  bi-anches  opposite  the 
meta'carpo-phalangeal  joint.  When  the  flap  is  stitched,  the  scar  will  be 
in  good  part  concealed  on  the  iilnar  aspect  of  the  stump. 

Second  Method. — A  transverse  dorsal  incision  is  made  over  the  articu- 
lation, extending  half  around  and  ending  at  opposite  points  on  the  external 
and  internal  lateral  aspects  of  the  thumb.     Parallel  lateral  incisions  are 


r 


r\ 


f        ! 


V  i 


made  as  far  forward  as  the  interphalangeal  joint,  and  the  anterior  ex- 
tremities of  these  are  joined  by  a  transverse  palmar  cut  (Fig.  166).  The 
end  of  the  metacarpal  bone  of  the  thumb  should  be  left  undisturbed, 
when  not  necrosed,  when  there  is  sound  skin  enough  to  cover  it  in. 
Under  other  conditions  it  may  be  divided  with  a  fine  saw  or  the  exsector. 
The  question  of  the  appearance  of  the  stump  should  be  secondary  to  the 
usefulness  of  the  member.  It  is  especially  important  to  a  laborer  that 
the  end  of  the  metacarpal  bone  of  the  thumb  be  preserved  (Pig.  167). 
When  the  operation  is  performed  upon  one  not  compelled  to  do  manual 
work,  a  more  symmetrical  appearance  may  be  obtained  by  an  oblique 
section  of  the  metacarpal  bone  about  half  an  inch  behind  the  articular 
surface.  When  this  is  intended,  the  incision  through  the  skin  should  be 
such  that  the  long  part  of  the  flap  is  obtained  from  the  radial  and  palmar 
aspect  of  the  thumb,  while  the  line  of  sutures  is  situated  well  on  the 
dorsal  surface  of  the  stiimp  (Fig.  168). 


AMPUTATIONS.  123 

Index-Finger — At  the  Metacarpo-PTialangeal  Joint — First  Method. 
— When  possible,  the  following  method  should  be  adopted,  the  object 
being  to  preserve  the  tactile  sense  and  to  leave  the  scar  less  prominent : 

From  the  ulnar  side  of  the  knuckle,  and  just  over  the  joint,  make 
an  incision  which  extends  from  this  j)oint  forward  as  far  as  the  web 
between  the  index  and  middle  finger,  and,  in  case  of  a  large  knuckle,  a 
little  beyond  this  point  at  the  side  of  the  digit.  From  the  anterior  end 
of  this  incision  make  a  second  cat  directly  across  the  palmar  aspect  of 
the  phalanx  until  the  middle  of  the  radial  side  of  the  finger  is  reached, 
and  complete  the  flap  by  cutting  in  a  straight  line  from  this  point  to  the 
commencement  of  the  first  incision.  When  the  disarticulation  is  com- 
pleted, the  dorsalis  and  radialis  indicts  arteries,  and  the  external 
digital  branches,  tied  with  fine  catgut,  the  corner  of  the  fiap  is  carried 
into  the  receding  angle  on  the  dorsal  surface  of  the  metacarpal  bone 
and  secured  by  sutures.  When  the  head  of  the  metacarpus  is  to  be 
removed,  the  section  of  this  bone  should  be  slightly  oblique,  and  the 
line  of  incision  a  partial  oval,  beginning  at  the  web  between  the  two 
fingers,  and  traveling  along  the  crease  formed  by  flexion  of  the  finger 
on  the  metacarpus  well  up  on  the  dorsum  of  this  bone,  about  three 
fourths  of  an  inch  back  of  the  joint.  An  incision,  almost  in  a  straight 
line,  should  now  be  made  between  the  ends  of  this  curved  line  (Fig.  166). 
Dissect  the  flaps  clear  and  without  making  a  disarticulation,  expose  the 
bone,  and  with  a  fine  saw  divide  it  obliquely  from  before  backward,  and 
from  the  ulnar  toward  the  radial  aspect.  In  amputation  of  the  middle 
or  the  ring  finger,  the  following  method  should  be  preferred : 


(After  Esmaroh.) 


Middle  Finger. — Locate  the  articulation  exactly,  and  over  this  point 
make  a  transverse  incision  extending  on  either  side  to  the  middle  of  the 
depression  between  this  digit  and  the  index-  and  ring-fingers  (Fig.  1 66). 
From  either  end  of  this  cut  carry  a  lateral  incision  directly  forward  about 


124:  A  TEXT-BOOK   ON  SURGERY. 

half  way  up  the  first  phalanx,  and  connect  these  by  a  transverse  incision 
across  the  palmar  aspect  of  the  digit  (Fig.  167).  Disarticulate  and  fold 
the  palmar  end  of  the  flap  back  upon  the  dorsal  transverse  incision  where 
it  is  stitched. 

Another  method  is  the  oval  incision,  shown  in  Pigs.  169  and  170.  By 
the  first  method  the  tactile  surface  is  better  preserved.  The  head  of  the 
metacarpal  bone  should  be  left  intact  for  the  laboring  classes.  When 
the  round  expansion  of  this  bone  is  removed,  the  gap  between  the  index- 
and  ring-fingers  is  not  so  wide.  The  bone  should  be  sawed  squarely 
across  a  half  inch  behind  the  articular  surface.  All  that 
has  been  said  of  this  digit  applies  with  equal  force  to  the 
ring-finger. 

Little  Finger. — The  method  recom- 
mended in  amputation  of  the  index  at 
the  metacarpal  joint  should  be  pre- 
ferred in  removing  the  little  finger  at 
the  same  level.  The  flap  should  be  so 
shaped  that  the  cicatrix  will  fall  on  the 
dorsum  and  toward  the  ring-finger. 
When  the  metacarpal  bone  is  to  be  di- 
vided it  should  be  cut  with  a  slight  ob- 
liquity. In  this  operation  the  oval  in- 
cision shown  in  Fig.  171  should  be  made. 
FiG.no.— (After Esmarch.)        When  two  or  more  fingers  require        no.  171. 

to  be  removed  at  the  metacarpo-phalan- 
geal  joint,  each  one  may  be  amputated  by  the  methods  described  as 
especially  suited  to  it,  or  a  common  antero-posterior  flap  may  be  made. 
As  to  the  propriety  of  removing  the  ends  of  the  metacarpal  bones,  the 
same  rules  apply  as  already  given  for  the  single  amputations. 

Througli  the  Metacarpus. — When  the  end  of  the  metacarpus  can  not 
be  saved,  these  bones  should  be  divided  at  any  point  three  fourths  of  an 
inch  or  more  anterior  to  the  carpo-metacarpal  articulation.  If  the  injury 
extends  behind  this  line,  it  is  better  to  disarticulate  at  the  carpo-meta- 
carpal junction.  In  amputation  through  the  metacarjDus,  the  flap  should 
be  made  chiefly  from  the  palmar  tissues,  so  that  the  line  of  sutures  and 
the  scar  will  be  well  on  the  dorsum  of  the  hand,  and  as  much  of  the 
tactile  sense  preserved  as  is  possible. 

Carpo-Metacarpal  Disarticulation. — When  all  the  bones  of  the  meta- 
carpus require  to  be  removed,  on  account  of  a  lesion  not  involving  the 
anterior  row  of  the  carpus,  the  amputation  should  be  made  through  the 
metacarpo-carpal  line.  If  the  anterior  row  is  involved,  the  entire  carpus 
should  be  removed.  When  the  thumb  is  intact,  and  the  metacarpal 
bones  of  the  four  fingers  require  removal,  the  incision  as  given  by 
Esmarch  should  be  followed.  A  curved  incision  is  made  across  the  palm, 
beginning  at  the  middle  of  the  web  between  the  thumb  and  index-finger, 
and  carried  outward  to  the  ulnar  side  of  the  base  of  the  fifth  metacarpal 
bone  (Fig.  172).  The  dorsal  incision  commences  at  the  web  between  the 
thumb  and  finger,  and  is  carried  obliquely  upward  toward  the  carpus 


AMPUTATIONS. 


125 


until  the  j  unction  of  the  middle  and  upper  third  of  the  metacarpal  bone 
of  the  index-finger  is  reached,  whence  it  travels  across  the  bacli  of  the 
hand  to  join  the  end  of  the  palmar  incision  (Figs.  173,  174). 


Amputation  of  the  thumb  with  disarticulation  at  the  carpo-metacarpal 
junction  should  be  done  as  follows  :  Just  over  the  carpo-metacarpal  joint 
on  the  dorsal  aspect  of  the  hand  commence  an  incision,  and  carry  it 
directly  along  the  metacarpal  bone  until  half  way  to  the  metacarpo-pha- 
langeal  articulation,  from  which  point  it  is  made  to  travel  along  the 
groove  between  the  thiimb  and  index-finger  to  the  middle  of  the  web 
between  these  two  members,  thence  on  around  the  base  of  the  thumb 
until  the  dorsal  incision  is  reached  (Fig.  175).     In  the  case  shown  in 


Fig.  176. — Epithelioma  of  thumb. 
(From  a  patient  at  Mt.  Sinai  Hospital.) 


Fig.  177. — The  same,  after  amputa- 
tion at  the  cai"po-inetaearpal  joint. 


Mgs.  176  and  177  this  operation  was  performed.  In  amputation  of  the 
little  finger,  at  the  carpo-metacarpal  joint,  a  similar  incision  is  made 
(Fig.  178). 

The  character  of  the  injury,  the  general  condition  of  the  individual. 


126 


A  TEXT-BOOK   ON   SURGERY. 


the  vitality  of  the  parts  involved,  may  necessitate  various  modifications 
of  the  foregoing  methods.  In  the  surgery  of  the  hand,  the  rule  in  prac- 
tice should  be  never  to  amputate  when  possible  to  avoid  it,  and  never  to 
remove  any  more  than  is  absolutely  necessary.  Fig.  179  is  that  of  an 
amputation  after  an  injury  from  the  explosion  of  a 
shot-gun,  in  which  the  thumb,  in- 
dex, and  middle  fingers,  and  their 
respective  metacarpal  bones,  were 
blown  off.  The  line  of  incision  was 
a  lateral  one,  and  the  disarticulation 
was  at  the  carpo-metacarpal  joint. 

Badio-Carpal  Joint. — Inampu-  T 

tation  at  the  wrist  the  carpus  shoul  d  / 

be  removed,  even  when  all  the  bones 
of  this  group  are  not  involved.    The 
line   of  Lucision  will  depend  upon       ^ 
the  extent  of   the  healthy  tissues       f 
available  for  forming  the  covering       ;/ 
to  the  stump.    The  long  palmar  and 
short  dorsal  flaps  are  preferable  on 
account  of  the  finer  tactile  sense  of        ^, 
the  covering  thus  secured.     More-        p  4 

over,  the  vitality  of  the  palm  is        ^  t 

so  great  that,  if  ordinary  precau-         p. 
tions  are  observed  in  its  dissection,         ^  ^ 

sloughing  wiU  not  occur.  ^-  ^ 

First  Method. — Place  the  thumb       f^  % 

and  finger  of  the  left  hand  respect-       '  "~°^| 

ively  upon  the  styloid  of  the  radius 
and  ulna,    and  make  an  incision  fig.  i79. 

across  the  dorsal  surface  of  the  wrist 
which  shall  divide  everything  straight  down  to  the 
bones  and  into  the  cavity  of  the  joint.  This  incision 
reaches  half-way  dq\vn  the  lateral  aspects  of  the  wrist. 
At  the  radial  end  of  this  cut  enter  the  scalpel,  and,  in 
shaj)ing  the  long  flap,  follow  the  center  of  the  dorsum 
of  the  metacarjDal  bone  of  the  thumb  as  far  as  the  meta- 
carpo-phalangeal  articulation.  From  this  point  cut  di- 
rectly across  the  palm  to  the  ulnar  side  of  the  fifth 
metacarpal  bone,  and  back  along  this  to  join  the  dorsal 
incision.  Dissect  the  flap  closely  from  the  flexor  ten- 
dons, and  divide  all  tendons  opposite  the  wrist-joint. 
Api)ly  a  cloth  retractor,  and  saw  through  the  styloid  of 
Fig.  180.  the  radius  and  ulna  just  at  the  level  of  the  articular 

surface  of  the  radius,  but  not  necessarily  taking  a  sec- 
tion from  this  surface.  The  radial.,  ulnar.,  anterior,  ?in(i  posterior  carpal 
vessels  are  tied,  the  palmar  flap  is  trimmed  down  to  fit  snugly,  and  stitched 
in  proper  position.    The  drainage-tubes  come  out  on  either  side  (Fig.  180). 


AMPUTATIONS. 


127 


Second  Method. — If  the  condition  of  the  soft  tissues  is  snch  that  the 
long  palmar  flap  can  not  be  obtained,  the  circular  incision  shown  in  Figs. 
181  and  182  may  be  practiced.  It  is  always  advisable  to  make  a  longitu- 
dinal split  in  the  cuff  along  its  iilnar  aspect.     Under  other  conditions,  a 


Fig.  182. — Showing  cuif  stitched 
and  exit  of  drains  <after  the 
circular  method.  (After  Es- 
maroh.) 


lateral- flap  may  be  ixtilized,  after  the  third  method  (Figs.  183,  184),  in 
the  flap  from  the  thumb  side  ;  or  the  fourth  method  in  which  the  flap 
is  taken  from  the  ulnar  as^Dect  of  the  hand. 

Forearm,  above  the  Wrist. — In  amputations  through  the  forearm,  the 
circular  or  modified  circular  skin-flaps  are,  in  general,  preferable.  The 
exceptions  are  in  cases  of  marked  emaciation  when  the  solid  flaps  are 
indicated. 

The  anatomical  relations  of  the  parts  concerned  are  admirably  shown 
in  Figs.  185,  186,  187,  and  188,  which,  with  only  slight  modifications,  I 
have  copied  from  Prof.  Braune's  magnificent  work. 

When  the  line  of  amputation  is  so  close  to  the  elbow-joint  that  divis- 
ion of  the  bones  is  necessitated  within  an  inch  of  the  articular  surface  of 
the  head  of  the  radius,  the  operation  to  be  preferred  is  a  disarticulation 
at  the  elbow,  with  removal  of  the  olecranon.  When  the  bones  can  be 
preserved  at  the  level  of  the  lower  border  of  the  bicipital  tuberosity  of 
the  radius,  the  joint  should  not  be  invaded. 

Amputation  at  this  level  (Fig.  188)  should  be  made  subject  to  the 
rales  just  given  for  other  portions  of  the  forearm  between  the  wrist  and 
the  insertion  of  the  bicevs  humeri. 


128 


A  TEXT-BOOK   ON   SURGERY. 


At  tJte  Elbow- Joint  —  First    Method.  —  Make    a    circular    incision 
through  the  skin  from  one  inch  to  one  inch  and  a  half  below  the  level  of 

the  internal  condyle.  Along 
the  posterior  aspect  of  the 
ulna  make  a  second  incision, 
splitting  the  sleeve  of  skin 
as  far  back  as  the  end  of  the 
olecranon.  Dissect  up  the 
flap  from  the  muscles  and 
deep  fascial  attachment  until 
the  joint  is  exposed  in  front, 
and  the  olecranon  posterior- 
ly. Extend  the  forearm  fully, 
enter  the  articulation  between 
the  head  of  the  radius  and 
the  humerus,  disarticulate, 
and  saw  off  the  articular  sur- 
face at  the  level  of  the  lower 
portion  of  the  internal  con- 
dyle. The  drainage  is  from 
the  highest  point  in  the  per- 
pendicular incision. 

Second  Method. — Make  a 
circular  incision  down  to  the 
deep  fascia  from  one  to  two  inches  anterior  to  the  tip  of  the  internal 
condyle  of  the  humerus,  and,  when  the  skin  has  retracted,  at  the  level 
of  the  line  of  reti-action  divide 
all  the  tissues  to  the  bones. 
Along  the  posterior  surface  of 
the  ulna  make  an  incision  ex- 
tending as  high  as  the  olecra- 
non process.  Dissect  the  soft 
tissues  neatly  from  the  perios- 
teum and  capsule  back  to  the 
condyles  on  the  lateral  and 
anterior  aspects  of  the  hume- 
rus, and  along  the  olecranon 
somewhat  higher,  in  order  to 
facilitate  disarticulation  and 
the  complete  removal  of  the 
synovial  bursa,  beneath  the  in- 
sertion of  the  triceps.  AVhen 
the  disarticulation  is  completed, 
apply  a  cloth  retractor  and  saw 
a  portion  of  the  articular  sur- 
face off  at  the  same  level  as 


Fig.  185.* — Transverse  section  through  tlie  right  upper  ex- 
tremity, one  fourth  of  an  inch  anterior  to  the  plane  of  the 
radio-carpal  articulation.  Lookinjf  at  the  surface  of  the 
stump.  1,  Radial  artery  and  veins.  2,  Ulnar  artery, 
veins,  and  nerve.  3,  Tendons  of  deep  and  superficial 
■  flexors.  4,  Tendon  of  extensor  ossis  metacarpi  and  primi 
internodii  poUicis.  5,  Flexor  cai-pi  radialis.  6,  Palmaris 
longus.  7,  Fibers  of  the  flexor  brevis  minimi  digiti,  from 
the  annular  ligament.  8,  Fle.xor  carpi  ulnaris.  9,  10, 
Extensor  carpi  radialis  longior  et  bi-cvior,  and  tendon  of 
seoundi  internodii  pollicis.  11,  Extensor  communis  digi- 
torum.  12,  E.xtensor  minimi  digiti.  13,  Extensor  carpi 
radialis.  Superficial  veins  and  nerves  are  seen  in  the 
subcutaneous  tissues. 


1<IG.  186.— Transverse  section  showing  the  relations  of  the 
tissues  divided  in  amputation  through  the  lower  third 
of  the  nght  foreai-m.  Looking  from  helow  upward. 
1,  Kadial  artery  and  veins.  Just  helow  this,  tendon  of 
supmator  longus,  radial  nerve,  and  close  to  the  radius 
the  tendons  of  the  extensor  ossis  metacarpi  pollicis 
and  extensor  carpi  radialis  longior  and  brevior.  2, 
iJlnar  artery,  veins,  and  nerve.  3,  Median  nerve. 
4,  5,  ihe  posterior  and  anterior  interosseous  arteries. 


*  All  of  these  cuts  represent  the  surface  nearest  the  patient's  bodj,  i.  e.,  the  surface  over 
which  the  vessels  are  searched  for  after  an  amputation. 


AMPUTATIOlSrS. 


129 


given  in  the  preceding  operation.    The  flaps  are  now  sutured,  leaving  the 
di"ainage-tube  out  at  the  upper  limit  of  the  incision,  over  the  olecranon. 


Fig.  187. — Transverse  section  thmurrli  the  middle  of  the  Tight  forearm.  Lookine;  from  the  periphery  toward 
the  center.  Showing  the  relations  of  the  tissues  divided  in  amputation  at  Siis  point.  1,  Kadial  artery, 
veins,  and  nerve.     2,  Dinar  ditto.     3,  Median  nerve.    4,  Anterior  interosseous  vessels. 


Fib.  188. — Transverse  section  through  the  upper  third  of  the  richt  forearm.  Looking  from  the  periphery 
toward  the  center.  1,  IJadial  artery,  muscular  branches,  veins,  and  radial  nerve.  2,  Dinar  and  inter- 
osseous arteries,  veins,  and  median  nerve.  3,  Dinar  nerve.  The  tendon  of  insertion  of  the  biceps  is 
seen  with  the  radius. 


130 


A  TEXT-BOOK   ON   SURGERY. 


Fig.  189  shows  the  anatomical  relations  near  the  line  of  section  of  the 
soft  parts  involved  in  this  amputation. 

In  no  amputation  is  the  superiority  of  the  circular  or  modified  circu- 
lar skin-Jiap  over  the  mixed  flap  of  older  operators  more  evident  than 
the  one  under  consideration.  In  the  mixed  operation,  v^here  the  anterior 
flap  was  made  by  transfixion,  cutting  obliquely  forward  and  outward,  the 
large  vessels  were  not  evenly  divided,  nor  was  it  without  considerable 
care  that  the  opposing  flaps  could  be  properly  adjusted.  The  older 
method,  in  which  the  olecranon  process  was  left  in  position,  the  saw  pass- 
ing through  the  neck  of  this  process  at  the  level  of  the  lower  portion  of 
the  articular  surface  of  the  humerus  as  soon  as  the  joint  was  opened,  has 
also  been  discarded.  It  has  been  demonstrated  that  nothing  was  gained 
by  leaving  the  insertion  of  the  triceps  intact,  while  a  second  operation 
was  occasionally  necessary  on  account  of  necrosis  of  the  olecranon. 

Removal  of  a  portion  of  the  articular  surface  is  not  always  advised  by 
surgical  writers.  While  it  is  true  that  the  stump  will  heal  as  readily 
when  the  cartilage  is  scraped  from  the  bone  as  when  the  saw  is  used,  the 
latter  is  preferable,  not  only  from  the  standpoint  of  appearance,  but  also 
that  of  usefulness. 


-"Sr^_sr-s_-"~;s 


Fig,  189. — Transverse  section  of  right  arm  JU^t  bLloi\  the  elboiN  joint  Looking  at  the  surface  nearest  the 
body.  1,  Brachial  artery  at  the  point  ot  division  into  ulnai  and  radial.  2,  Median  basilic  vein  com- 
municating with  brachial.  3,  The  radial  and  interosseous  divisions  of  the  musculo-spiral  nerve  and 
radial  recurrent  artery.  4,  Tendon  of  biceps.  5,  Median  nerve  and  anterior  ulnar  recurrent  artery.  6, 
Ulnar  nerve  and  posterior  ulnar  recurrent  artery. 


Arm  helow  the  SJioulder- Joint. — The  circular  skin-flap  is  always  pref- 
erable, except  in  cases  of  extreme  emaciation,  when,  as  heretofore  given, 
the  solid  flaps  are  recommended. 

First  Method. — Make  a  circular  cut  down  to  the  muscles,  and  a 


AMPUTATIOXS. 


131 


longitudinal  incision  to  the  same  depth,  along  the  outer  side  of  the  arm. 
Dissect  the  sleeve  of  skin  carefully  up   to  the  line  of  section  of  the 
humerus,   and   at   this  point  divide 
the    muscles    and   bone.      Drainage 
is  effected  in  the  manner  shown  in 
Fig.  190. 

The  anatomical  relations  in  the 
several  regions  of  the  arm  are  shown 
in  Figs.  191.  192,  and  193. 

When  the  line  of  amputation  is 
so  near  the  shoulder-joint  that  sec- 
tion of  the  bone  is  requii-ed  at  the 
anatomical  neck,  the  head  of  the 
humerus  should  be  disarticulated. 

Second  MefTiocl. — Make  a  cu-ciilar 
cut  through  the  skin  at  a  point  suf- 
ficiently belovr  the  line  of  section 
through  the  humerus  to  permit  a 
suitable  covering.  Allow  the  skin 
to  retract  up  the  arm,  and  at  this 
point  divide  everything  smoothly 
and  squarely  down  to  the  bone. 
Render  the  skin  and  muscles  tense, 

push  the  point  of  the  scalpel  down  to  the  bone  on  the  outer  side  of  the 
arm,  and  lay  the  flap  open  by  an  incision  which  is  parallel  with  the 
axis  of  the  humerus.  Dissect  the  tissues  closely  from  the  periosteum 
up  to  the  point  where  the  saw  is  to  be  applied,  and,  after  protecting 


fiG.  190. — Showing  sutures  applied  and  exit  of 
drains  in  ampntation  at  the  lower  and  mid- 
dle thirds  of  the  hmnems. 


Fig.  191. — Section  throush  the  condyloid  expansion  of  the  right  arm.  Looking  at  the  snrface  nearest  the 
bodT.  1,  Brachial  arterr  and  veins,  and  the  median  basilic  vein.  2,  Musculo-.'piral  nerve  and  superior 
protnnda  .irtery  about  tie  point  of  anastomosis  with  the  radial  recurrent.  3,  Median  nerve,  -i,  Biceps 
tendon.    5,  Ulnar  nerve.     6,  Triceps  tendon. 


132 


A  TEXT-BOOK   ON  SURGERY. 


Fig.  192.— -Transverse  section  through  lunction  of  middle  and  lower  thuds  of  light  arm.  Looking  from  below 
upward.  1,  Biachial  aitery,  vein,  median  ncive,  and  basilic  vein  Neai  by  the  ulnar  nerve  and 
inferior  profunda  aiteiy  2,  Museul-)  pml  nci\p,  superior  profunda  aitery,  and  supinator  longus  mus- 
cle.    Cephaho  \ eiu  to  outer  side  ot  1 1 1    I       [     ujustle. 


193.— Transverse  section  showing  the  relations  of  parts  divided  in  amputation  just  above  the  middle  of 
the  humerus  Eight  side.  Looking  toward  the  center.  1,  Brachial  artery.  Near  this  the  median  nerve 
and  brachial  veins.  Internal  to  it  the  ulnar  nerve  and  inferior  profunda  artery.  More  superficial, 
tbe  basilic  vein.  2,  Musculo-spiral  nerve  and  superior  profunda  artery.  3,  Nutrient  artery  in  the  sub^ 
stance  of  the  coraco-brachialis  muscle,    i,  Cephalic  vein. 


A^IPUTATIOXS. 


133 


the  soft  parts  witli  a  retractor,  diTide  tlie  bone.  The  drainage  should 
be  from  the  upper  extremity  of  the  perpendicular  cut.  which,  with  the 
stump  properly  elevated,  will  be  the  most  dependent  portion  of  the 
wound.     An  extra  tube  may  be  inserted  at  the  end  of  the  stump. 

At  the  Shoulder- Joint — jFirst  Method. — The  patient  should  be 
placed  so  that  the  shoulder  is  near  the  comer  of  the  table  and  conven- 
ient to  the  operator.  After  rendering  the  extremity  bloodless,  apply 
the  elastic  tourniquet  around  the  axilla  and  over  the  clavicle  and  spine 
of  the  scapula.  Holding  the  arm  so  that  the  internal  condyle  points 
directly  to  the  patient's  side,  enter  a  long,  sharp  scalpel  directly 
down  to  the  capsule  of  the  joint,  just  at  the  articulation  of  the  clavicle 
with  the  acromion  process,  and  expose  the  head  and  upper  part  of  the 
humerus  by  a  per- 
pendicular incision, 
which  splits  the  del- 
toid down  to  its 
insertion.  At  the 
lower  end  of  this 
incision  make  a  cir- 
ci;lar  cut  through 
the  skin,  and,  al- 
lowing it  to  retract, 
divide  at  this  line 
the  remaining  soft 
tissues  do^vn  to  the 
bone.  In  order  to 
prevent  any  bleed- 
ing, in  case  the  tour- 
niquet should  not 
be  sufficiently  tight, 
an  assistant  should 
be  ready  to  grasp 
the  flap  just  below 
the  tourniquet,  or 
press  the  subclavian 
against  the  first  rib. 
The  entire  flap  is 
now  dissected  up 
from  the  periosteum 
and     capsule,     and  ^la-  i^*- 

disarticulation      ac- 
complished   by  cutting   the   capsule    as  close  to   the  margin  of    the 
glenoid   cavity  as   possible   (Fig.   194).     The  vessels  are  now  secured, 
and   the   wound   sutured   and   drained,    as   shown  in   Fig.    195.      This 
method  is  a  modification  of  the  old  operation  of  Larrey.*  to. which  it 

*  Larrey's  JfetJiod. — A  straight  incision,  dividing  all  the  tissues  down  through  the  capsule 
to  the  bone,  extending  from  the  tip  of  the  acromion  process  to  about  one  inch  below  the  articu- 
lar surface  of  the  head  of  the  humerus.     From  the  center  of  this  cut  an  incision  on  either  side 


134 


A   TEXT-BOOK   ON   SURGERY. 


is  much  superior.  Esmarch  has  still  further  modified  this  amputation 
by  sawing  the  bone  immediately  after  the  circular  incision  is  com- 
pleted, and  then  disarticulating. 
Amputation  of  All  or  Por- 
tions of  the  Scapula  and  Clav- 
icle.— When  it  becomes  neces- 
sary to  remove  all  or  parts  of 
these  bones,  the  deligation  of 
the  subclavian  artery  in  its 
third  division  should  be  first 
accomplished. 

As  this  amputation  is  occa- 
sionally necessitated  by  reason 
of  malignant  neoplasm,  involv- 
ing the  integument,  it  may  be 
found  impossible  to  secure  flaps 
,^  sufficient  to  cover  the  exposed 
^>  surface.  Under  such  conditions 
the  wound  should  be  allowed  to 
heal  by  granulation  and  a  sub- 
sequent plastic  operation  done 
to  cover  in  the  stump. 

LowEE  Extremity. 

Amputation  of  the  Toes. — The  same  methods  given  for  the  fingers 
should  be  employed  in  amputation  of  the  toes.  The  long  plantar  flap  is 
preferable  in  these  operations,  not  so  much  for  the  preservation  of  the 
more  perfect  tactile  sense  of  this  surface  in  covering  the  stump,  but  chiefly 
to  bring  the  cicatrix  on  top  and  away  from  pressure.  When  an  ampu- 
tation is  necessitated  for  a  lesion  near  the  articulation  between  the  first 
and  second  phalanges  in  which  only  the  anterior  extremity  of  the  first 

of  the  arm,  running  obliquely  downward  and  forward,  dividing  all  the  tissues  down  to  the  peri- 
osteum, and  extending  about  two  thirds  of  the  distance  from  the  apex  of  the  shoulder  to  the 
axilla.  Elevate  the  tissues  so  as  to  fully  expose  the  joint,  press  the  arm  upward,  in  order  to 
dislocate  the  head  of  the  bone  through  the  incision  in  the  capsule,  carry  a  long,  thin  knife  across 
and  through  the  capsule,  and  complete  the  oval  iiap  by  cutting  along  the  under  surface  of  the 
humerus  in  the  line  of  tlie  oblique  incisions  already  made. 

Dupuytreri's  Method. — Place  the  arm  to  be  amputated  at  a  right  angle  to  the  trunk,  grasp 
and  raise  the  deltoid  with  the  left  hand,  and  transfix  the  shoulder  from  before  backward  with 
a  long  knife,  which  is  introduced  anterior  to  the  axillary  vessels,  perforates  the  capsule,  and 
emerges  on  the  posterior  aspect  of  the  arm.  A  long  {deltoid)  flap  is  now  made  by  cutting  down- 
ward, close  to  the  bone,  to  near  the  deltoid  tubercle.  While  an  assistant  holds  this  flap  up  out 
of  the  way,  the  arm  is  carried  to  the  side  of  the  body,  and  the  humerus  pressed  upward,  in 
order  to  facilitate  its  dislocation.  The  long  head  of  the  biceps,  and  the  tendons,  inserted  into 
the  tuberosities,  are  now  divided,  and,  if  necessary,  the  incision  in  the  capsule  lengthened. 
After  the  luxation  is  accomplished,  insert  the  knife  as  in  the  operation  of  Larrey,  making  the 
posterior  flap  by  the  same  mancsuvre. 

[Many  other  methods  have  been  devised  for  the  performance  of  this  operation,  but  the 
method  first  given  meets  all  the  indications  so  fully  that  it  must  supersede  all  others.] 


AMPUTATIONS. 


135 


/^■,^ 


phalanx  is  involved,  section  throngh.  the  bone  should  be  preferred  to 
disarticulation  at  the  metatarso-phalangeal  joint,  provided  that  the  line 
of  section  is  through  the  anterior  thii'd  of  the  phalanx.  Disarticula- 
tion of  two  or  more  consecutive  toes  at  the  metatarso-phalangeal  joint 
may  be  effected  by  a  continuous  incision.  Amputation  of  all  the  toes  at 
this  articulation  is  performed  as  follows  :  Grasp  and  forcibly  flex  the 
toes,  and  make  an  incision,  commencing  just  i)Osterior  to  the  inner  aspect 
of  the  metatarsal  joint  of  the  great  toe,  curving  forward  along  the  side  of 
the  first  phalanx  to  a  point  as  far  advanced  as  the  web 
between  the  toes,  and  then  across  the 
base  of  each  digit  on  this  plane  until 
the  outer  side  of  the  metatarsal  bone 
of  the  fifth  toe  is  reached  at  a  point 
corresponding  to  that  at  which  the 
incision  was  begun.  With  the  toes 
now  fully  extended,  a  symmetrical 
flap  is  next  cut  along  the  jilantar  as- 
pect by  an  incision  which  almost 
merges  into  the  first  line  at  the  ante- 
rior margin  of  the  web  (Figs.  196, 197). 
Dissect  up  each  flap  as  far  back  as 
the  metatarso-phalangeal  articulation, 
leaving  the  tendons  to  be  divided  at 
this  point.  The  disarticulation  may 
be  best  effected  with  a  strong  narrow 
Fig.  196.  scalpel,  while  the  ligaments  are  made  fig.  197. 

tense  by  forced  flexion. 
Second  Method. — A  separate  amputation  may  be  made  for  each  toe. 
Through  the  Metatarsus. — When  the  loss  of  tissue  requires  an  ampu- 
tation behind  the  metatarso-phalangeal  articulation,  section  of  one,  or 
even  all,  of  the  metatarsal  bones  should  be  effected  rather  than  unneces- 
sarily sacrifice  any  portion  of  the  foot  by  disarticulation  at  the  tarso- 
metatarsal joint.  The  line  of  section  should  always  be  as  near  the  anterior 
extremity  as  possible,  and  when  it  falls  within  three  fourths  of  an  inch  from 
the  tarso-metatarsal  joint,  a  disarticulation  should  be  made  at  this  point. 
Amputation  through  the  entire  metatarsus  should  be  made  with  a 
long  plantar  and  short  dorsal  flap,  so  that  the  scar  will  fall  on  the 
dorsum  of  the  foot  and  away  from  pressure.  The  dorsal  incision  should 
be  made  almost  directly  across  the  foot,  and  on  a  line  with  the  plane  of 
section  through  the  bones.  The  plantar  flap  should  begin  on  the  inner 
side  of  the  first  metatarsal  bone,  and  follow  this  forward  as  far  as  is 
necessary  to  secure  a  flap  of  sufiicient  length.  It  is  always  wise  to  make 
this  a  little  too  long,  so  that  it  may  be  trimmed  down  and  made  to  fit 
nicely  as  the  sutures  are  being  adjusted.  The  incision  is  next  carried 
across  the  sole  of  the  foot  to  the  outer  surface  of  the  metatarsal  bone  of 
the  little  toe,  and  back  along  this  to  the  point  of  junction  with  the  end 
of  the  dorsal  cut.  All  of  the  tissues  should  be  divided  directly  down  to 
the  bones  in  this  incision,  and  the  flap  dissected  up,  keeping  the  knife- 


136  A  TEXT-BOOK  ON  SURGERY. 

point  always  in  contact  with  the  periosteum,  so  that  the  vessels  may  be 
avoided.  After  the  bones  are  sawn  through,  the  lower  flap  is  turned  into 
position  and  suitably  trimmed.  The  vessels  are  next  secured,  the  sutures 
applied,  and  the  drainage-tubes  brought  out  at  each  side. 

At  the  Tar so-Metatar sal  Articulation — First  Metatarsal. — Amputa- 
tion of  the  great  toe,  with  disarticulation  of  its  metatarsal  bone  at  the 
tarsal  joint,  is  effected  as  follows  :  At  a  point  about  half  an  inch  behind 
the  articulation  of  the  metatarsal  bone  with  the  internal  cuneiform,  and 
immediately  between  the  dorsal  and  internal  lateral  aspects  of  this  bone, 
commence  an  incision  which  is  carried  forward  to  the  phalangeal  junction. 
Thence  it  is  continued  around  the  base  of  the  toe,  across  its  plantar  sur- 
face, and  back  through  the  web  between  the  first  and  second  digits,  and 
back  to  the  end  of  the  straight  incision  over  the  metatarso-phalangeal 
joint  (Fig.  198).  Dissect  the  soft  parts  closely  from  the  bone,  taking  care 
not  to  wound  the  plantar  vessels,  and  disarticulate.  The  preservation  of 
the  posterior  portion  of  the  first  metatarsal  bone  is  always  desii'able,  on 
account  of  its  giving  insertion  to  the  peroneus-longus  and  partially  to  the 
tibialis-anticus  muscle,  the  former  being  a  strong  sup]3orter  of  the  trans- 
verse arch  of  the  foot,  and  the  latter  offering  the  chief  resistance  to  the 
sural  muscles. 


Fifth  Metatarsal. — One  fourth  of  an  inch  behind  the  tubercle  of  the 
fifth  metatarsal,  and  over  the  center  of  the  dorsal  aspect  of  this  bone, 
commence  an  incision,  which  is  carried  directly  forward  until  near  the 
first  phalanx,  when  an  oval  is  described  around  the  base  of  the  little  toe 
(Pig.  199).  Keep  close  to  the  bone  in  the  dissection.  The  disarticulation 
is  more  easily  effected  by  division  of  the  peroneus  brevis  and  peroneus 
tertius,  and  by  entering  the  articulation  from  the  outer  side.  The 
importance  of  the  posterior  portion  of  this  bone  is  less  than  that  of 
the  metatarsal  bone  of  the  great  toe,  but  it  should  never  be  needlessly 
sacrificed. 

One  or  more  of  the  intervening  metatarsal  bones  may  be  removed  in 
an  amputation  of  their  respective  toes  in  practically  the  same  manner  as 
the  preceding.  The  incision  should  be  begun  far  enough  behind  the 
tarso- metatarsal  joint  to  thoroughly  expose  the  ligaments  and  facilitate 
disarticulation — not  an  easy  process  when  only  a  single  bone  is  to  be 
removed.  The  incision  should  be  made  exactly  along  the  middle  line  of 
the  dorsal  aspect. 


AMPUTATIONS. 


137 


^O^r 


A, 


Amputation  of  the  entire  metatarsus  should  always  be  made  through 
the  articular  plane  (Lisfranc).  The  modification  of  this  procedure  by 
Hey,  which  consisted  in  disarticulating  the  four  outer  metatarsal  bones 
and  sawing  the  end  of  the  internal  cuneiform  oflE  at  the  line  of  the  second 
metatarsal  bone,  is  altogether  unnecessary. 

Method — Dorsal  Incision. — Place  the  thumb  and  index  of  one  hand 
respectively  half  an  inch  behind  the  articulations  of  the  first  and  fifth 
metatarsal  bones  with  the  cuneiform  and  cuboid,  and  at  the  most  con- 
venient one  of  these  points  commence  the  dorsal  incision,  carrying  it, 
directly  forward  to  the  base  of  the 
metatarsus,  and  then  across  the  foot 
one  fourth  of  an  inch  in  front  of  the 
tarso-metatarsal  articulation,  finish- 
ing at  the  opposite  side  (Fig.  200). 
This  incision  shoiild  have  a  slight 
forward  convexity,   and  should  di- 
vide all  tissues  down  to  the  bones. 
Dissect  the  flap  closely   from  the 
periosteum  to  about  one  fourth  of 
an  inch  behind  the  line  of  articula- 
tion. 

Plantar  Flap. — From  the  same 
point  as  for  the  dorsal  incision,  carry 
the  knife  directly  forward  on  the  lat- 
eral aspect  of  the  metatarsal  bone 
Fig.  200.  to  the  metatarso-phalaugcal  joint, 

where   the  line   of  incision   should 
begin  to  describe  a  curve  until  the  interdigital  web  is  reached,  along 
which  it  travels  across  the  foot,  and  thence  back  along  the  oi:)posite 
metatarsal  bone  to  the  level  of  the  tarsus  (Fig.  201). 

This  flap  should  be  lifted  by  deep  dissection,  keeping  close  to  the 
under  surface  of  the  bones,  in  order  to  interfere  as  little  as  possible  with 
the  vascular  supply.  An  assistant  should  now  hold  both  flaps  well 
back,  while  with  a  narrow,  short  scalpel  the  disarticulation  is  effected 
as  follows : 

Grasp  the  metatarsus  with  one  hand  and  forcibly  defjress  it  until  the 
ligaments  are  put  upon  the  stretch.  Enter  the  knife  just  behind  the  tip 
of  the  fifth  metatarsal  bone  and  carry  it  inward  with  a  slight  forward 
inclination,  disarticulating  on  this  plane,  and  in  succession  the  fifth, 
fourth,  and  third  bones,  until  the  knife  is  arrested  by  the  outer  surface 
of  the  second  metatarsal.  The  line  of  this  articulation  is  almost  parallel 
with  that  just  followed,  but  it  is  placed  from  one  eighth  to  one  fourth  of 
an  inch  posterior  to  it,  and  may  be  readily  found  by  moving  the  meta- 
tarsal bone  upon  the  cuneiform.  The  joint  between  the  metatarsal  bone 
of  the  great  toe  and  the  internal  cuneiform  is  about  one  fourth  of  an  inch 
anterior  to  that  of  its  fellow,  being  continuous  with  the  line  of  the  three 
outer  bones.  The  flaps  should  now  be  trimmed  and  nicely  fitted,  and 
any  ragged  ends  of  tendons  clipped  off  by  the  scissors,  after  which  the 


138 


A  TEXT-BOOK   ON  SUEGERY. 


Pirogoff. 


vessels  are  tied  and  tlie  sutures  adjusted,  leaving  the  drainage-tubes  out 
at  each  angle. 

One  point  of  precaution  is  essential,  namely,  to  avoid  division  of 
that  part  of  the  tendon  of  the  tibialis  anticus  which  is  inserted  into 
the  internal  cuneiform  near  its  metatarsal  articulation.  One  of  the 
objections  to  this  operation  is  the  elevation  of  the  heel,  and  the  con- 
sequent depression  of  the  stump  by  the  action  of  the  sural  muscles, 

which  action  is  practically  unop- 
posed if  the  insertion  of  the  tibi- 
alis anticus  is  divided.  Should  this 
occur,  or  should  the  heel  be  too 
greatly  elevated,  the  tendo  Achillis 
should  be  divided  as  in  talij^es  equi- 
nas.  The  line  of  section  through 
the  internal  cuneiform  bone  is 
shown  in  Fig.  202.  This — the  op- 
eration of  Hey — is  objectionable, 
for  two  reasons.  In  the  first  place, 
it  cuts  away  a  part  of  the  bony 
framework  of  the  foot,  which  need 
not  be  sacrificed  ;  and,  secondly,  it 
severs  the  attachment  of  the  tibi- 
alis-anticus  mxiscle. 

ThrougJi  the  Tarsus.  — When 
removal  of  any  part  of  the  ante- 
rior row  of  tarsal  bones  is  re- 
quired, the  following  rules  should 
be  adopted :  If  the  internal  cunei- 
form is  involved  only  on  its  ante- 
rior articular  surface,  it  may  be 
sawn  through  on  the  line  of  Hey 
(Fig.  202).  If  the  middle  or  ex- 
ternal cuneiform  is  involved  only 
to  a  limited  extent  upon  its  ante- 
rior portion,  as  much  as  one  fourth 
of  an  inch  of  this  surface  may  be 
sawn  or  scraped  ofl:.  Behind  this 
limit  a  disarticulation  from  the 
Fig.  202.  scaphoid  should  be  made.    Through 

the  cuboid  the  section  should  pass, 
as  first  advised  by  Dr.  S.  F.'  Forbes,  of  Toledo,  Ohio  (who  performed  this 
operation  in  1863),  through  the  middle  of  this  bone  on  the  line  of  the 
anterior  surface  of  the  scaphoid  (Fig.  202). 

Forbes^ s  Method. — Disarticulation  of  the  three  cuneiform  bones  from 
the  scaphoid,  and  section  of  the  cuboid  parallel  with  the  plane  of  the 
anterior  surface  of  the  scaphoid  (Fig.  202).  The  dorsal  and  plantar  in- 
cisions are  slightly  anterior  to  and  practically  the  same  as  in  Chopart's 
amputation.     The  dissection  should  be  made  closely  from  the  bones,  and 


continuity. 


continuity. 


AMPUTATIOXS. 


139 


^^ 


the  flaps  tiimmed  and  adjusted  as  in  the  preceding  operation.  Section 
of  tendo  A  chillis  may  be  done  later,  if  necessaiy. 

Medio-Tarsal — Operation  of  CJiopart. — The  dorsal  incision  is  begun  on 
a  level  with  and  an  inch  posterior  to  the  tip  of  the  base  of  the  fifth  meta- 
tarsal bone  (for  the  adult  foot).  This  point  is  about  one  fourth  of  an  inch 
behind  the  articulation  between  the  cuboid  and  calcaneum  (Figs.  199,  203). 
"With  a  slight  forward  conrexitY  the 
incision  is  carried  across  the  top  of 
the  foot  to  the  posterior  margin  of 
the  tuberosity  of  the  scaphoid,  and 
then  directly  back  from  one  fourth 
to  half  an  inch  (Fig.  198).  The  skin, 
tendons,  vessels,  and  nerves  are  di- 
vided on  this  line,  and  the  flap  lift- 
ed untU  the  joiats  between  the 
astragalus  and  scaphoid  and  the 
calcaneum  and  cuboid  are  well  ex-  Pig.  oos, 

posed.     From  the  ends  of  this  first 

incision  a  long  plantar  fiap  is  fashioned  by  cutting  forward,  as  in  shaping 
the  flap  for  the  operation  of  Lisfi'anc  (Figs.  198,  199 1.  Disarticulation  is 
effected  with  a  short,  strong  scalpel,  whUe  forcible  extension  is  employed. 
The  flaps  are  now  to  be  properly  trimmed,  and  the  vessels  secured. 
Division  of  the  tendo  Achillis  may  be  done  later.  "When  requii-ed,  this 
operation  may  be  modified  by  sawing  off  the  anterior  half-inch  of  the 
astragalus  and  calcaneum.     The  incisions  are  practically  the  same. 

Calcaneo-Astragaloid  Disarticulation. — This  operation  was  first  sug- 
gested by  Lignerolles,  first  performed  by  Textor,  but  brought  into  promi- 
nence by  Malgaigne.  "When  in  an  amputation  of  the  foot  at  the  medio- 
tarsal  joint  it  is  discovered  that  the  os  calcis  must  also  be  removed,  and 
if  the  astragalus  is  sound,  the  subastragaloid  operation  should  be  pre- 
feiTed  to  the  amputation  of  Syme  at  the  tibio-tarsal  joint.  By  this 
method  a  shortening  of  about  two  inches  is  prevented,  and.  although  the 
under  surface  of  the  astragalus  is  uneven,  experience  has  shown  that  the 
pressure  is  safely  distributed,  and  a  useful  stump  results.  ]\loreover,  the 
degree  of  mobility  maintained  at  the  tibio-astragaloid  articulation  adds 
to  the  ease  and  comfort  of  locomotion. 

Seize  the  foot  with  the  left  hand,  and  with  a  strong  scalpel  commence 
the  incision  by  dividing  the  skin  and  tendo  Achillis  just  at  the  level  of  the 
upper  surface  of  the  os  calcis.  From  this  point  the  incision  is  continued 
along  the  fibular  side  of  the  foot  fonvard.  dividing  everything  down  to  the 
bone,  and  curving  slightly  downward  until,  as  it  passes  below  the  tip  of  the 
external  malleolus,  it  is  four  tenths  of  an  inch  below  this  point  (Fig.  204). 
The  line  of  incision  is  now  carried  directly  forward  until  near  the  tuber- 
osity at  the  base  of  the  fifth  metatarsal  bone,  where  it  curves  to  the  dor- 
sum of  the  foot,  crossing  to  the  inner  side  over  the  anterior  edge  of  the 
scaphoid,  and  then  straight  do'mi  and  under  the  foot  a  half-inch  beyond 
the  middle  of  the  sole  (Figs.  205,  206).  From  this  point  a  straight  incision 
is  made  dii'ectly  back  to  the  point  of  beginning  at  the  inner  edge  of 


140 


A  TEXT-BOOK   ON  SURGEET. 


the  tendo  AcMllis  (Fig.  206).     Lift  the  plantar  flap  by  deep  and  careful 
dissection  from  the  bone,  leaving  nothing  but  the  periosteum,  until  the 


Fig.  204.— (After  Malgaigue.) 


FiQ.  205.— (After  Malgaigne.) 


calcaneo-astragaloid  articulation  is  well  exposed.  The 
flaps  being  held  by  an  assistant,  the  disarticulation  is 
begun  by  opening  the  astragalo-scaphoid  joint  and 
removing  the  anterior  part  of  the  foot  at  the  medio- 
tarsal  joint.  The  os  calcis  should  now  be  seized  with 
a  lion-tooth  forceps,  and  the  disarticulation  of  this 
bone  effected.  The  exposed  tendons  should  be  smooth- 
ly divided  with  the  scissors  at  the  higher  portions  of 
the  incision.  After  deligation  of  the  vessels  the  flap 
is  properly  trimmed  and  sutured,  the  cicatrix  falling 
upon  the  dorsal  and  external  lateral  aspects  of  the 
stump.* 

*  Hancock's  modification  of  this  procedure,  or  the  subastragaloid- 
osteop]a?tic  amputation,  is  as  follows:  One  incision  begins  beneath 
and  at  the  posterior  angle  of  the  outer  malleolus,  and  is  carried  along 
the  outer  surface  of  the  foot  to  a  point  a  half-inch  anterior  to  the  pro- 
jecting base  of  the  fifth  metatarsal  bone.  A  second  incision  is  made 
along  the  inner  border  of  the  foot,  commencing  posteriori}'  about  the  center  of  the  internal 
malleolus  and  terminating  anteriorly  at  a  spot  opposite  the  end  of  the  external  incision.  The 
anterior  ends  of  both  cuts  are  joined  by  a  curved  in- 
cision made  with  its  convexity  forward  across  the 
plantar  aspect  of  the  foot,  and  dividing  all  the  tis- 
sues well  down  to  the  bone.  Eetleot  this  flap  back 
as  far  as  the  projections  at  the  under  surface  and  in 
front  of  the  tuberosity  of  the  os  calcis,  and  make  a 
fourth  incision  across  the  dorsum  of  the  foot  imme- 
diately behind  the  head  of  the  astragalus.  -Apply  the 
saw  upon  the  under  surface  of  the  calcaneum  a  little 
anterior  to  its  center,  and  cut  through  the  bone  ob- 
liquely from  below  upward  and  backward  (Fig.  207). 
With  the  knife  enter  the  mediotarsal  joint,  pass  the 
instrument  under  the  head  of  the  astragalus,  and,  cut- 
ting from  before  backward,  sever  the  interosseous  ligament  and  detach  the  anterior  part  of  the 
foot,  together  with  the  segment  of  the  os  calcis.  Saw  oif  the  head  of  the  astragalus,  and  with 
a  sharp  bone-cutter  (or  saw)  remove  the  two  articular  cartilages  (and  a  thin  slice  of  bone)  from 
the  under  surface  of  the  astragalus.  As  the  flaps  are  adjusted,  the  sawn  surface  of  the  calca- 
neum is  brought  into  apposition  with  the  under  surface  of  the  astragalus.  See  "Lancet,'' 
September,  1866,  p.  257. 


Fig.  207. — Section  of  os  calcis  and  astragalus 
in  Hancock's  operation. 


AMPUTATIONS. 


141 


Amputation  of  the  Foot— Tlhio- Tar  sal  {Syme^s). — When  the  astraga- 
lus must  be  removed,  together  with  the  foot,  the  amputation  of  Syme, 
which  involves  a  disarticulation  of  the  tibio-astragaloid  joint,  and  a  sub- 
sequent section  of  the  articular  surfaces  of  the  tibia  and  fibula,  should 
be  made.  In  its  successful  performance  certain  precautions  are  neces- 
sary, chief  among  which  is  the  preservation  of  the  proper  vascular  sup- 
ply to  the  posterior  flap.  The  failure  to  appreciate  the  importance  of 
making  the  plantar  incision  far  enough  forward,  as  laid  down  by  Syme, 
has  brought  this  procedure  somewhat  into  disrepute,  for  Prof.  Stephen 
Smith,  in  his  comprehensive  report,  says  the  necessity  for  re-amputation 
is  3  per  cent  greater  in  this  than  in  any  other  amputation. 

In  my  "Prize 
Essay,"  published 
in  1876,*  I  demon- 
strated that  the  ar- 
terial distribution 
to  the  calcaneo- 
plantar  flap  was 
chiefly  derived 
from  the  external 
plantar  artery,  and 
from  the  posterior 
tibial  so  near  the 
bifurcation  of  this 
vessel  into  its  ter- 
minal branches, 
that  any  line  of  in- 
cision in  the  forma- 
tion of  this  flap 
which  necessitated 
the  application  of 
a  ligature  at  or  very 
near  its  bifurcation 
was  not  justifiable. 
I  do  not  doubt  that 

the  sloughing  so  often  met  with  at  this  point  is  caused  by  carrying  this 
incision  too  far  back  toward  the  tuberosity  of  the  calcaneum.  The  arte- 
rial supply  is  shown  in  Fig.  208,  from  my  "Essays  in  Surgical  Anatomy 
and  Surgery."  f 

Modified  Procedure. — With  the  foot  held  at  an  angle  of  90°  to  the 
axis  of  the  leg,  place  the  thumb  at  the  tip  of  one  malleolus,  and  the 
index  at  the  other,  and  from  the  center  of  the  malleolus  internus  carry  an 
incision  directly  across  the  sole  of  the  foot  to  a  point  one  fourth  of  an 
inch  anterior  to  the  tip  of  the  malleolus  externus.  This  incision  should 
divide  all  the  tissues  to  the  bones,  and,  as  will  be  seen  in  Figs.  20.9  and 
210,  its  perpendicular  portion  descends  in  a  direction  slightly  anterior  to 


Fig.  208.— Diagram  showing  the  arterial  supply  to  the  calcanean  region,  on 
the  tibial  side  of  the  foot.  (Drawn  by  the  author,  from  the  average  of 
eighty -seven  disseetions.)  m,  Internal  malleolus,  pmcn,  Tibio-tarsal 
quadrilateral,  the  surgical  region  of  this  articulation,  i,  Posterior  tibial 
artery,  o,  Its  point  of  bifurcation  into  y.  Internal  plantar,  and  /,  Ex- 
ternal plantar  artery,  i  i  i.  Calcanean  branches  of  external  plantar,  t, 
Articular  branches  from  posterior  tibial,  h.  Articular  branch  from  in- 
ternal plantar.  ^,  Tendon  of  tibialis  posticus  muscle,  r,  Tendon  of 
flexor  tongus  digitorum.  «,  Tendon  of  flexor  longus  poUiois.  m  c,  The 
line  of  incision  of  Gross,  m  I,  m  d,  m  e,  m  e.  Lines  of  incision  showing 
that  the  nearer  the  incision  approaches  the  heel,  the  more  danger  is  in- 
curred of  cutting  off  the  principal  blood-supply  to  the  calcanean  flap,  in 
amputation,  mn.  Line  crossing  the  usual  point  of  bifurcation  of  the 
posterior  tibial,    ma,  mi,  Anterior  incision. 


*  "  American  Journal  of  the  Medical  Sciences,"  April,  1876. 


t  William  Wood  &  Co.,  1879. 


142 


A  TEXT-BOOK   ON  SURGERY. 


the  axis  of  the  tibia.  The  ends  of  this  cut  are  united  by  a  second,  which 
arches  sharply  upward  about  on  the  line  of  section  of  the  bones,  and 
should  also  divide  tendons  and  all  intervening  structures,  opening  into 
the  joint.     The  foot  should  now  be  firmly  grasped  and  extended,  so  as 


to  make  tense  the  anterior  ligament  of  the  ankle,  which  is  easily  divided. 
Carrying  the  knife  to  either  side  of  the  articular  surfaces  of  the  astra- 
galus, the  lateral  ligaments  are  cut,  and  the  joint  thus  widely  exposed. 
An  assistant  now  holds  and  depresses  the  foot,  while  the  operator  care- 
fully dissects  the  tissues  closely  from  the  astragalus  and  calcaneum. 
Care  should  be  taken  not  to  bruise  the  flap  by  too  great  traction.  In 
dissecting  along  the  inner  surface  of  the  ankle,  the  knife  should  be  kept 
close  to  the  bones,  so  that  when  the  lesser  process  of  the  calcaneum  is 
reached  it  will  slide  behind  and  under  this  process,  passing  between  it 
and  the  flexor  tendon  and  the  vessels.  If  this  precaution  is  not  taken, 
the  arteries  may  be  wounded  and  the  nutrition  of  the  flap  seriously  im- 
paired. As  the  dissection  proceeds, 
the  foot  is  further  depressed,  and  the 
tendo  Achillis  separated  from  its  in- 
sertion into  the  tuberosity  of  the  cal- 
caneum, in  doing  which  care  must  be 
taken  not  to  button-hole  the  flap.  The 
posterior  portion  of  the  os  calcis  may 
now  be  brought  through  the  joint,  and 
the  dissection  continued  in  this  direc- 
tion or  finished  by  working  back  along 
the  under  surface  of  this  bone.  After 
the  foot  is  removed,  the  flaps  are  lifted 
from  the  tibia  and  fibula  until  a  sec- 
tion of  these  bones  can  be  made  just 
on  the  level  of  the  anterior  articular 
margin  of  the  tibia  (Fig.  211).  It  is 
Fig.  211.  not  uecessary  to  remove  the  articular 
surface.  The  flaps  should  now  be 
trimmed  and  fitted,  and  the  vessels  tied.  .  As  the  sutures  are  applied,  it 
will  be  noticed  that  there  is  a  redundancy  of  tissue  in  the  long  flap,  leav- 
ing a  cup-shaped  cavity  ;  but  this  can  be  thoroughly  drained  from  the 
angles  of  the  wound,  and  disappears  when  the  stump  is  healed  (Fig.  212). 


^' 


Fig.  -ilJ..  —Mump  iiltei 
Syrae's  amputation. 
(After  Malgaigne.) 


AMPUTATIONS. 


143 


Syme's  amputation,  at  the  anMe  has  been  modified  by  the  osteoplastic 
operations  ot  Pirogoff,  Le  Fort,  Gunther,  and  others. 

Pirogoff's  Method. — The  dorsal  and  plantar  incisions  are  made  from 
the  same  iDoints,  and  are  practically  the  same  as  in  Syme's  amputation. 
However,  in  order  to  avoid  redundancy  of  the  soft  tissues  and  to  expose 
the  calcaneum  back  to  the  line  of  section  of  this  bone,  the  lower  incision 
should,  when  it  reaches 
the  sole  of  the  foot, 
be  carried  back  about 
three  f  oirrths  of  an  inch 
nearer  the  lieel  than  in 
Syme's  method.  The 
dorsal  incision  does  not 
ascend  so  high  upon 
the  ankle  by  the  same 
distance.  The  joint  is 
opened  through  the  an- 
terior incision,  and  the 
lateral  ligaments  di- 
vided until  the  ante- 
rior upper  surface  of 
the  OS  calcis  can  be  dis- 
placedf  orward  through 
the  articulation,  when 
it  is  sawn  through  on 
the  line  indicated  in  Fig.  214,  the  instrument  running  parallel  with  the 
edges  of  the  iucision.  The  soft  parts  are  now  carefully  lifted  from  the 
articular  ends  of  the  tibia  and  fibula,  and  these 
bones  divided  horizontally  so  that  aU  the  articu-         |;  | 

lar  cartilage  is  removed  by  the  section.     The  an-         l  / 

gle  described  by  these  two  lines  of  section  is 
about  90°  (Fig.  214).  The  flaps  are  adjusted  so 
that  the  iDlane  of  the  calcaneum  is  brought  snugly  .  , 


Fig.  213.— (After  Esmareh.) 


Fig.  215. — Stump  aner  Pirogoff's 
amputation.  (After  Malgaigne.) 

in  apposition  with  that  of  the  tibia  and  fibula.     The  drainage  should  be 
from  the  dependent  angles  of  the  wound  (Fig.  215). 

Le  Fort's  MetTtod. — Three  fourths  of  an  inch  below  the  external 


144 


A  TEXT-BOOK  ON  SURGERY. 


malleolus  commence  an  incision  whicli  is  carried  directly  forward  to 
within  half  an  inch  of  the  calcaneo-cnboid  articulation.  From  this  point 
it  describes  a  curve  with  an  anterior  convexity  over  the  dorsum  of  the 
foot,  following  the  line  of  the  astragalo-scaphoid  joint  until  the  tuner 
border  of  the  foot  is  reached  (Fig.  216),  when  it  is 
carried  back  and  ended  at  a  point  about  one  ,"":'=  f^X 

inch  in  front  of  the  tip  of  the  internal  mal- 
leolus, which  point  is  directly  between  the  tuber- 
osity of  the  scaphoid  and  the  tip  of  the  mal- 


FiG.  216.— (After  Le  Fort.) 


Fig.  217.— (After  Le  Fort.) 


leolus.  From  the  anterior  limit  of  the  straight  incision  below  the  ex- 
ternal malleolus  describe  a  plantar  flap  also  with  a  forward  convexity 
across  the  sole  of  the  foot,  as  shown  in  Fig.  217.  Dissect  up  the  dor- 
sal flap,  in  order  to  exj)ose  the  tibio-tarsal  joint,  taking  great  care  in 
lifting  the  inner  angle  not  to 

wound  the  tibial   and  plantar  -^^^ 

arteries.     The  disarticulation  of 


1  After  Le  Fort. 


Fio.  21S.— (After  Le  Fort  ) 

the  astragalus  from  the  calca- 
neum  is  next  effected  by  intro- 
ducing a  thin  knife  from  the 
fibular  side  between  these  bones, 

and  dividing  the  interosseous  ligament.  Then  remove  the  front  of  the 
foot  at  the  medio-tarsal  joint,  and  complete  the  disarticulation  of  the 
astragalus,  and  with  the  saw  remove  the  upper  segment  of  the  calcaneum 
on  the  level  of  its  articular  surface  (Figs.  218,  219).     The  tibia  and  fibula 


AMPUTATIONS. 


145 


are  now  horizontally  divided  just  at  tlie  level  of  the  articular  plane  of  the 
tibia,  as  ta  Syme's  operation  (Fig.  212).  In  adjusting  the  flaps,  the  savm 
surface  of  the  calcaneum  is  brought  into  apposition  with  that  of  the  tibia 
(Fig.  220).  Or,  having  exposed  the  tibio-tarsal 
joint,  divide  the  ligaments,  disarticulate,  as  in 
Syme'  s  operation,  and,  having  drawn  the  astra- 
galus and  calcaneum  forward  untU  the  upper 


Fig.  220. — Stump  after  Le  Fort's 
amputation.    (Le  Fort.) 


portion  of  the  as  calcis  is  exposed,  insert  a 
key-hole  saw  behind  the  tuberosity,  and  saw 
through  this  bone  on  the  line  already  indicated. 
Gunther's  modification  of  this  procedure  is  shown  ia  Figs.  221,  222, 
223,  224,  225,  taken  from  Esmarch's  hand-book,  and  the  crescentic  section 


of  the  bones,  as  practiced  by  P. 
Bruns,  is  seen  in  Fig.  226,  from 
the  same  source. 
Summary.— 'hi.  amputations  of  the  foot  the  following  rules  should  be 
observed :  The  terminal  phalanges  of  all  the  toes  should  be  removed  by 
disarticulation  when  it  becomes  necessary  to  remove  a  portion  of  the  en- 
tire thickness  of  these  bones.     The  same  rule  applies  to  aU  the  second 

10 


146  A  TEXT-BOOK   ON   SURGERY. 

phalanges,  except  that  of  the  great  toe,  which  should  be  sawn  through  at 
any  point  anterior  to  its  middle.  If  a  section  posterior  to  this  is  re- 
quired, disarticulate  from  the  metatarsal  bone.     What  has  been  said  of 

the  second  phalanx  of  the  great  toe 
applies  with  equal  force  to  the  proxi- 
mal phalanges  of  all  the  other  toes. 

None  of  the  metatarsal  bones  should 
be  disarticulated  from  the  tarsus  when 
a  section  is  possible  not  less  than  three 
fourths  of  an  inch  anterior  to  each 
tarso-metatarsal  joint. 

When  a  section  posterior  to  this 
line  is  required,  a  tarso-metatarsal  dis- 
articulation should  be  effected.  Key's 
operation  is  only  justifiable  when  the 
anterior  face  of  the  internal  cuneiform  is  diseased.  As  much  as  the 
anterior  fourth  of  each  cuneiform  bone,  and  the  anterior  half  of  the 
cuboid,  may  be  sawn  off,  in  preference  to  the  sacrifice  of  the  bony 
frame-work,  by  Forbes' s  or  Chopart's  operation. 

When  the  cuneiform  bones  must  be  removed,  and  the  posterior  half 
of  the  cuboid  is  sound,  Forbes's  operation  should  be  preferred  to  Cho- 
part's. Chopart's  procedure  is  next  in  order.  The  sub-astragaloid 
operation  should  always  be  preferred  to  a  tibio-tarsal  (Syme's)  amputa- 
tion. If  the  condition  of  the  parts  is  such  that  the  vitality  of  the  flap  is 
assured,  the  operations  of  Le  Fort  and  Pirogoff,  carefully  and  skillfully 
done,  should  be  preferred  to  the  tibio-tarsal  disarticulation. 

Even  at  the  risk  of  a  second  operation  being  required,  an  effort  to 
preserve  the  greatest  jDossible  portion  of  the  foot  is  justifiable,  except 
when  it  may  seriously  threaten  the  life  of  the  patient.  The  value  of  a 
surface  accustomed  to  pressure  can  only  be  thoroughly  appreciated  in 
the  after-adjustment  of  an  artificial  apparatus. 

Leg. — Amputation  at  any  portion  of  the  leg  above  the  line  of  section, 
in  Syme's  operation,  should  be  made  by  one  of  two  methods. 

1.  Modified  Circular  SJcln-Flap. — At  a  sufficient  distance  beyond  the 
point  at  which  the  bones  are  to  be  divided  make  a  circular  cut  through 
to  the  deep  fascia,  split  the  flap  directly  over  the  fibula,  up  to  the  point 
of  section  through  the  bones,  and  carefully  dissect  up  the  cuff.  When 
the  flap  is  reflected,  at  the  level  of  its  base  divide  all  the  soft  tissues 
squarely  down  to  the  bones,  which  are  next  sawn  through.  The  spine  of 
the  tibia  should  be  trimmed  down,  to  prevent  too  acute  pressure  and 
sloughing  of  the  skin  at  this  point,  a  not  infrequent  occurrence  when  this 
precaution  is  omitted.  The  drainage  is  at  the  fibular  side,  and,  as  the 
leg  should  be  elevated,  the  tube  should  come  out  at  the  highest  point  of 

-the  perpendicular  incision.  When  the  bones  are  sawn  through  within 
six  inches  of  the  knee-joint,  the  remainder  of  the  fibula  should  be 
exsected. 

2.  Method  of  Prof.  Stephen  Smith. — Commence  an  incision  in  the 
center  of  the  anterior  surface,  and  carry  it  downward  along  the  side  of 


AMPUTATIONS. 


U7 


the  leg,  so  as  to  make  a  slightly  curved  flap,  with  its  convexity  below ; 
when  the  incision  passes  over  the  prominent  part  of  the  leg  toward  the 
posterior  surface,  incline  it  upward  until  the  middle  of  the  limb  is 
reached,  where  it  should  be  continued  directly  up  to  the  point  at  which 
the  bone  is  to  be  divided  ;  make  a  similar  incision  on  the  opposite  side 
(Fig.  227) ;  the  flaps,  consisting  of  the  skin  and  fascia,  are  dissected  up- 


Fic.  227.— (After  Stephen  Smith.) 


ward  about  an  inch,  at  which  point  the  muscles  are  divided  squarely 
down  to  the  bones.  After  the  bones  are  divided,  the  hood  is  brought 
over  the  stump  and  sutured,  leaving  the  drainage  at  the  upper  part  of 
the  posterior  incision. 

In  very  emaciated  subjects,  to  forestall  the  liability  of  sloughing  in  the 
flaps,  the  first  circular  cut  should  go  dii'ectly  through  all  the  tissues  down 
to  the  bones,  and  the  perpendicular  incision  along  the  fibula  also  down 
to  this  bone.  All  the  tissues  should  then  be  lifted  closely  fi'om  the  peri- 
osteum and  interosseous  membrane,  forming  a  solid  flap,  reflected  up  to 
the  point  at  which  the  bones  are  to  be  divided. 

"When  the  line  of  amputation  approaches  nearer  than  three  inches 
from  the  upj)er  articular  siii-face  of  the  tibia,  a  complete  disarticulation 
at  the  knee  should  be  performed.  At  or  below  this  point  the  upi^er  por- 
tion of  the  bone  should  be  preserved,  and  the  fibula  exsected.  After 
recovery  from  the  operation  it  will  be  found  that  the  tibia  is  flexed  upon 
the  femur,  so  that,  in  the  adjustment  of  an  artificial  limb,  the  chief 
pressure  may  be  comfortably  borne  upon  the  normal  tissues  in  front  of 
the  patella  and  the  tuberosity  of  the  tibia.  The  gi'eater  pressure  in  any 
prothetic  apparatus  used  after  amputation,  at  or  above  the  knee,  falls 
upon  the  ischio-j)erineal  region.* 

*  The  older  operations,  which  consisted  in 
making  a  long  and  a  short  flap  on  opposite 
sides  of  the  leg,  are  now  fallen  into  general 
disuse.  The  requirements  will  be  better  ful- 
filled by  any  one  of  the  methods  already  de- 
scribed than  by  the  more  complicated  meth- 
ods of  Teale,  Lee,  Sedillot,  and  others. 

Method  of  Teale — Long  and  Short  Rec- 
tangular Flaps. — The  long  flap,  folding  over 
the  end  of  the  bone,  is  formed  of  parts  gen- 
erally devoid  of  large  blnod-vessels  and  nerves, 

which  structures  are  left  in  the  short  flap.  '      "^'  ""''        ^  '^     i^an.j 

The  size  of  the  long  flap  is  determined  by  the 
circumference  of  the  limb  at  the  place  of  amputation,  its  length  and  breadth  being  each  etiual 


148 


A  TEXT-BOOK   ON   SURGERY. 


Knee-Joint. — First  Method — Modified  Circular  SMn-Flap. — About 
three  inches  below  the  patella  make  a  circular  sweep  around  the  leg, 

dividing  the  skin  and 
fascia.      Join  this  by 
a  perpendicular  incis- 
ion in  the  middle  line 
of    the    jjosterior    as- 
pect of  the  limb,  ex- 
tending   through   the 
skin  and  fascia,  and 
at  least  as  high  as  to 
the  level  of  the  top  of 
the   patella.      Dissect 
the  skin  back  carefully,  keeping 
close  to  the  anterior  surface  of 
the  patella,  as  the  skin  over  this 
bone  is  usually  very  thin.     It  is 
not  necessary  to  dissect  the  cuff 
as  high  on  the  lateral  and  poste- 
rior aspects  as  in  front,  since  the 
anterior  incision  is  made  to  allow 


Pig.  231.— (Modified  from  Esmarch  ) 


^)  '•'^^niiii 


Fig.  232.— (After  Esmiireli.) 


to  half  the  circumference  of  the  limh  at  this  point.     The  short  ilap  is  one  fourth  as  long  as 
the  other.     The  incisions  and  stump,  after  Teale's  method,  are  shown  in  Fig.  228. 

Sedillofs  Method — Long  Fibular,  Short  Tibial,  Flap. — Opposite  the  point  at  which  the 
bones  are  to  be  divided  insert  a  long,  thin,  amputating-knife,  the  point  of  which  shall  graze 
tlie  spine  of  the  tibia  and  the  outer  surface  of  the  fibula,  and   come  out  through  the  outer 


aspect  of  the  calf.     Cut  downward  close  to  the  bones,  and  make  a  long,  rounded  ilap.     The 
■short  flap  is  made  by  an  incision  with  a  slight  downward  convexity  (Fig.  229). 


Fig.  230.— (Ashhurst's  "  Enoyclopfcdia.") 

Lee's  Method. — The  length  of  the  flaps  is  determined  as  in  Teale's  amputation.  The  long 
flap  is  posterior,  and  includes  the  skin  and  sural  muscles.  The  deep  muscles  and  the  vessels 
are  divided  squarely  at  the  base  of  the  flap  (Fig.  230). 


AMPUTATIONS. 


149 


Fig.  233. — Transverse  section  of  the  right  lee  ju-l  :il  "\r  ilie  ankle-joint,  showing  the  relation  of  the  parts  on 
the  plane  of  section  through  the  mallc'.li  in  Smiic's,  Pirogoff's,  Le  Fort's,  Gunther's,  and  Bi-uns'a 
amputations.  Looking  at  9ie  surface  nearest  tlie  body.  1,  E-xtensor  longus  digitorum.  2,  Anterior 
tibial  vessels  and  nerve.  3,  Extensor  proprius  pollicis.  4,  Tibialis  anticus.  5,  Internal  saphena 
vein.  6,  Tibialis  posticus.  7,  Flexor  longus  digitorum.  8,  Posterior  tibial  arteiy,  veins,  and  nerve. 
9,  Flexor  longus  polUcis.  10,  Tendo  Achillis.  11,  External  cutaneous  nerve.  12,  Peroneus  brevis. 
13,  Peroneus  Tongus. 


Fig.  234.— Section  through  lower  third  of  right  leg.    Looking  toward  the  center.     1,  Anterior  tibial  noire!, 
artery,  and  veins.     2,  Posterior  tibial  artery,  veins,  and  nerve.     3,  Peroneal  artery  and  veins. 


150 


A  TEXT-BOOK   ON  SURGERY. 


of  the  removal  of  the  patella  and  dissection  of  the  synovial  sac  just 
above  it.  Divide  the  tendon  of  the  quadriceps  at  the  upper  limit  of 
the  patella,  turn  this  down,  cut  the  lateral  ligaments  and  capsule  along 
the  edges  of  the  condyles  of  the  femur,  flex  the  leg  strongly  on  the 
thigh,  divide  the  crucial  ligaments,  and,  as  soon  as  the  posterior  liga- 
ment of  Winslow  is  exposed,  introduce  a  long  knife  and  remove  the  leg 
by  cutting  squarely  through  the  soft  tissues  at  the  back  of  the  articu- 
lation (Fig.  231).     A  cloth  retractor  is  now  applied  and  a  slice  of  bone 


Fio.  230.— Section  through  the  middle  of  the  n!;ht  kg  Lookmc;  from  below  upward  1,  Anterior  tibial 
artery,  veins,  and  nerve  2,  Pot,teuoi  tibial  aitery,  veins  and  nene  3  Peroneal  aituv  and  veins 
4,  Long  saphena  vein  and  neive.     5,  Muboulo-cutaneous  neive.     6,  Short  saphena  vein  and  nerve. 

removed  with  the  saw,  leaving  a  smooth  surface.  Should  the  articular 
end  of  the  femur  be  diseased,  the  section  may  be  made  high  enough 
to  remove  this,  provided  the  saw  does  not  enter  the  medullary  canal. 
With  the  cutting-forceps  round  oflf  the  sharp  edges  of  bone,  tie  the 
vessels,  and  close  the  flap  as  in  Fig.  232. 

Second  Method  {Operation  of  Prof.  8te2)7ien  S77iit7i).-AN\Wi  a  large 
scalpel  commence  an  incision  about  an  inch  below  the  tubercle  of  the 
tibia,  and  cut  to  the  bone  ;  carry  it  downward  and  forward  beyond  the 
curve  of  the  side  of  the  leg,  thence  inward  and  backward  to  the  middle 


A3IPUTATI0XS. 


151 


Fig.  236. — Section  through  upper  third  of  nght  k_' 
and  nerve      2,  Posterior  ditto.    3,  Peroneal  vessel 
vein  and  ner\  e 


t        I  t  11,  Anterior  tibial  vessels 

i,  iIu»Lulo-i,at.ineoua  neive.    5,  Internal  saphena 


of  tlie  leg,  thence  upward  to  the  middle  of  the  popliteal  space ;  repeat 
this  incision  ux^on  the  opposite  side  ;  raise  the  flaj),  consisting  of  all  the 
tissues,  down  to  the  bone  until  the  articulation  is  reached,  divide  the 
ligaments,  and  remore  the  leg  as  in 
the  previous  operation  (Fig.  237). 
The  flap  should  be  lifted  from  the 
patella,  and  this  bone  removed. 

"  Care  should  be  taken  that  the 
incision  is  inclined  moderately  for- 
ward 'down  to  the  curve  of  the  side 
of  the  leg,  to  secure  ample  covering 
for  the  condyles,  and  that  upon  the 
internal  aspect  it  should  have  addi- 
tional fullness  for  the  purpose  of  in- 
suring sufficient  flap  for  the  internal 
or  larger  condyle  "  (Smith).* 

*  The  metliod  of  Garden — namely,  long  anterior  skin-flap,  and  the  short  posterior  skin  and 
muscular  flap,  made  by  the  long  knife  carried  through  the  joint — is  inferior  m  every  respect  to 


Fig.  237. 


152 


A  TEXT-BOOK   ON  SURGERY. 


After  the  flaps  are  stitched  the  drainage-tube  makes  its  exit  through 
the  upper  posterior  angle  of  the  wound. 

When  in  amputation  near  the  knee  the  femur  is  the  seat  of  osteo- 
myelitis, the  indications  are  to  thoroughly  cleanse  the  canal  by  means  of 

a  long  Volkmann's  spoon  and  irri- 
gate with  sublimate  solution ;  intro- 
duce a  long  drainage-tube  the  tiiYl 
length  of  the  canal  and  bring  this  out 
through  the  flap  exactly  in  line  with 
the  axis  of  the  canal  (Fig.  237  a). 

In  this  way  the  danger  of  a  high- 
er amputation  is  avoided  and  a  longer 
stump  secured.  In  two  instances  of 
amputation  Just  above  the  knee,  after 
exsection  of  this  joint  in  which  osteo- 
myelitis occurred  in  the  femur,  I  car- 
ried out  this  practice  successfully. 

Irrigation  through  the  tube  should 
be    loracticed  about    the   seventh   day 
and  every  three  or  four  days  after  this,  and  the  tube 
gradually  shortened. 

Thigh.  — The  method  to  be  selected  in  amputations 
through  the  lower  two  thirds  of  the  thigh  wiU  depend 
upon  the  size  of  the  member  at  the  point  of  election. 
In  limbs  of  ordinary  size,  and  particularly  in  emaciated 
persons,  the  operation  advised  in  the  arm  should  be 
followed  here. 

First  Method. — Make  a  circular  incision  through 

the  skin  and  fascia,  joined  by  a  perxDendicular  cut  on 

the  lower  external  aspect  of  the  limb.     Dissect  up  the 

flap  from  the  muscles,  and  divide  aU.  the  remaining 

soft   tissues  squarely  at   the  point  of   section  of  the 

bone.    Suture  the  flap,  and  drain  from  the  outer  upper 

(and,  if  necessary,  lower)  angle. 

Second  Method. — Below  the  line  of  section  through  the  femur,  at  a 

distance  sufficient  to  furnish  an  ample  flap,  by  a  circular  incision  divide 

the  integument  down  to  the  muscles,  allow  the  skin  to  retract,  and  at  the 

line  of  retraction  divide  the  remaining  soft  tissues  down  to  the  bone. 

either  of  the  foregoing  operations.  Garden  recommended  section  through  the  condyles. 
Gritti  introduced  an  osteoplastic  modification  hy  making  a  long  rectangular  skin-flap  from 
the  front  of  the  knee  and  leg,  which  is  dissected  up  deeply,  lifting  the  patella  in  the  flap. 
Behind,  a  short  flap  is  made  similar  to  that  in  Carderi'a  method.  Section  is  made  through 
the  bone  about  an  inch  above  the  tip  of  the  internal  condyle,  and  the  articnlar  surface  of  the 
patella  is  then  sawn  off.  This  procedure  may  be  best  accomplished  by  grasping  the  flap  with 
the  left  hand  and  stretching  it  over  the  knuckles,  so  that  the  articular  surface  of  the  patella 
looks  directly  upward,  where  it  is  fixed  quite  immovably.  As  the  flaps  are  adjusted,  the 
sawn  surface  of  this  bone  is  brought  into  contact  with  that  of  the  femur.  Some  operators 
secure  it  here  by  transfixing  with  an  ivory  pin.  The  whole  procedure  is  not  only  difiicult  and 
tedious,  but  wholly  unnecessary. 


I 


AMPUTATIONS. 


153 


On  the  anterior  and  external  aspect  of  the  thigh,  by  a  perpendicular 
incision  extending  as  high  as  the  point  of  section  of  the  bone,  divide 
everything  to  the  bone,  and  from  the  periosteum,  with  a  dry  dissector, 
lift  the  solid  flap.  Apply  the  cloth  retractor  and  saw  through  the  bone. 
As  the  stumiD  is  placed  in  an  elevated  position,  with  the  thigh  also 


Fig.  238. — Section  through  the  right  femur  at  the  condyles  and  at  the  middle  of  the  patella.  Looking  at  the 
central  surface  as  exposed  after  amputation  at  this  point.  1,  Popliteal  artery,  vein,  and  internal  popliteal 
nerve.  2,  E.xternal  popliteal  or  peroneal  nerve.  The  capsule  and  the  synovial  cavities  are  admu'ably 
shown,  as  well  as  the  bursa  -mucosa  i    '  " 


abducted  and  rotated  outward,  the  drainage  is  naturally  at  the  upper 
angle  of  the  perpendicular  incision. 

At  the  Hip. — Proceed  as  follows :  Place  the  patient  so  that  the  hip 
at  which  the  operation  is  to  be  performed  projects  well  over  the  corner 
of  the  table.  The  member  to  be  amputated  is  emptied  of  blood  by 
elevation  and  the  Esmarch  bandage,  and  is  held  by  an  assistant  while 
the  opposite  thigh  is  abducted  and  allowed  to  drop  over  the  end  of  the 
table,  the  foot  resting  upon  a  stool.  Haemorrhage  may  in  great  part  be 
controlled  by  placing  a  compress  upon  the  iliac,  as  it  runs  along  the  rim 
of  the  pelvis,  and  holding  this  dowTi  and  in  position  by  a  strong  rubber 


154 


A  TEXT-BOOK   ON  SURGERY. 


tube,  carried  obliquely  around  the  groin  from  the  peringeum,  above  the 
anterior  spine,  and  over  the  crest  of  the  ilium.  An  abdominal  tourni- 
quet should  be  applied,  so  as  to  compress  the  aorta  at  a  point  one  inch 
to  the  left  of  the  umbilicus.  This  need  not  be  tightened  unless  compres- 
sion below  proves  inadequate.  * 

Operation. — Half  way  between  the  anterior-sujperior  spine  of  the  ilium 
and  the  upper  surface  of  the  trochanter  major  (the  extremity  being  held 
parallel  with  the  axis  of  the  body,  and  the  foot  normally  everted)  intro- 
duce a  strong  scalpel  straight  down  to  the  bone,  and  by  a  single  incision 
divide  all  the  tissues  along  the  head  and  neck,  over  the  middle  of  the 
great  trochanter,  and  down  the  outer  aspect  of  the  femur  for  three  or  four 
inches,  and  as  much  as  six  if  jDossible,  below  the  tip  of  the  trochanter. 
Arrest  the  bleeding  as  the  operation  proceeds.     Dissect  the  tendons 


Fig.  239.— (Modified  from  Esmarch.) 


from  their  insertion  into  and  near  the  trochanter,  using  the  cutting  edge 
of  the  knife  only  when  necessary,  preference  being  given  to  lifting  the 
soft  parts  from  the  periosteum  and  capsule  with  tlie  dry  dissector.  With 
strong  hook  retractors  the  edges  of  the  wound  are  separated,  the  joint 
exposed,  the  capsule  and  ligamentum  teres  divided,  and  disarticulation 
effected.  The  soft  parts  are  now  still  farther  lifted  from  the  bone,  to  a 
point  at  least  six  inches  below  the  trochanter.     The  entire  mass  of  soft 

*  If  no  other  raeaos  is  at  hanfl,  the  iliac  maybe  compressed  by  inti-odiicing  a  padded  staff 
into  the  rectum,  and  over  this  vessel  as  it  runs  along  the  pelvic  rim. 

Trendelenburg  recommended  transfixion  by  means  of  a  round  steel  pin,  which  is  passed 
between  the  head  of  the  femur  and  the  femoral  vessels.  Compression  is  maintained  by  the 
elastic  bandage,  thrown  over  the  end  in  figure-of-8  fashion. 


AMPUTATIONS. 


155 


tissues  is  now  constricted  by  a  second  elastic  tube,  or  ligature,  as  close  to 
tbe  body  as  possible,  and  this  intrusted  to  an  assistant,  whose  hands  also 
grasp  that  part  of  the  flap  in  which  the  large  vessels  are  located.  At  a 
point  as  low  as  possible,  or  about  six 
inches  from  the  trochanter,  make  a 
cii'cular  sweep  around  the  thigh, 
dividing  the  skin,  and  allow  this  to 
retract.  On  this  level  the  amj)uta- 
tion  is  to  be  completed  by  passing  a 
long  knife  behind  the  bone,  cutting 
squarely  back  through  all  the  re- 
maining tissues  (Fig.  239).  As  rap- 
idly as  possible  all  the  larger  vessels 
are  grasped  with  forceps,  after  which 
the  ligatures  are  applied.  The  drain- 
age should  be  from  the  cavity  of  the 
acetabulum,  out  at  the  upper  angle, 
and  at  each  of  the  two  lower  angles 
of  this  stump. 

Second   Method. — Six    or    seven 
inches  below  the  trochanter  make  a 

circular  incision  through  the  skin  and  fascia,  and  allow  this  to  retract. 
At  the  level  of  the  reti'acted  skin  divide  all  the  tissues  down  to  the  bone, 
and  saw  thi-ough  the  femur  at  this  level,  as  in  Dieffenbach's  procedure. 


Fig.  240.— (After  Esmarch.) 


Secure  all  vessels  at  once,  and  disarticulate  by  the  same  incision  as  prac- 
ticed in  the  preceding  operation. 

Third  Method  {ErsMne  Mason^s  Operation'^). — The  circulation  is  con- 

*  "  New  York  Medical  Journal,"  December,  1876. 


156 


A  TEXT-BOOK   ON   SURGERY. 


troUed  by  the  abdominal  tourniquet,  Esmarch's  bandage  having  been 
applied  up  to  the  line  of  incision.  About  seven  inches  below  the  level 
of  the  joint  make  a  circular  incision  through  the  skin,  turn  and  dissect 
this  up  as  high  as  the  head  of  the  femur.     With  the  scalpel  divide  the 


f^r 


Fk.  242. — Section  through  right  thigh  at  Hunter's  canal.    Looking  .it  tlie  surface  attached  to  the  tody.    1,  Fem- 
oral vessels  and  long  saphenous  nerve,    2,  Great  sciatic  nerve  and  arteria  comes.     3,  Long  saphena  vein. 

muscles  on  this  plane,  open  the  capsule,  and  dislocate  the  femur.     The 
anterior  vessels  should  be  first  secured. 

Fourth  Method— Transfixion. — A  knife,  the  blade  of  which  should 
be  at  least  fifteen  inches  long,  is  introduced  half-way  between  the  tro- 
chanter major  and  the  anterior-superior  iliac  spine,  the  thigh  being 


A:^IPrTATIONS. 


157 


sligMly  abducted  and  the  foot  in  the  normal  degree  of  eversion.  The 
blade  is  held  at  an  angle  of  90^  to  the  axis  of  the  body,  nntil  the  point  is 
felt  to  strike  and  pass  into  the  capsule  of  the  Joint,  when  the  handle  is 
elevated,  so  that  the  knife  is  parallel  with  Poiipart's  ligament,  and  so 
directed  that  its  point  will  emerge  on  the  inner  aspect  of  the  thigh,  near 
the  perinseum  (Fig.  240).  As  the  last  stej)  in  this  manoeuvre  is  being 
effected  the  thigh  should  be  slightly  flexed  on  the  abdomen,  in  order  to 


Fe^^-" 

N 

, 

J 
^V. 

\ 

X 

.*r» 

O 

Fig.  243. — Section  through  left  thigh  at  its  middle.  Looking  at  the  surface  attached  to  the  hody.  1, 
Superficial  femoral  artery,  vein,  and  saphenous  nerve.  2.  Great  sciatic  nerve,  and  the  arteria  comes 
nervi  ischiadic!.  3,  Tenninal  branch  of  profimda  femoris.  4.  Descending  branch  of  external  circumfles. 
5,  Long  saphenous  vein. 

relax  the  tissues  here  and  allow  the  knife  to  pass  well  beneath  the  great 
vessels.  Two  precautions  are  necessary,  namely,  not  to  push  the  knife- 
point into  the  obturator  foramen,  and  also  to  avoid  wounding  the  scrotum 
or  labium.  By  to-and-fro  sweeps  of  the  knife,  which  is  made  to  pass 
along  upon  the  bone  for  about  seven  inches,  a  flap  about  eight  inches  in 
length  is  cut  on  the  anterior  and  inner  aspect  of  the  thigh.     As  soon  as 


158 


A  TEXT-BOOK   ON   SURGERY. 


the  knife  shall  have  traveled  downward  a  suflBcient  distance  to  permit  it, 
an  assistant  should  insert  his  middle-  and  index-fingers  into  the  wound, 
and,  wich  the  aid  of  the  thumbs  applied  externally,  control  the  vessels 
by  dhect  pressure.  The  two  femoral  arteries  and  veins  should  be  at 
once  secured. 

The  capsule  should  now  be  divided  with  a  short,  strong  scalpel,  the 
head  of  the  bone  forcibly  luxated,  the  long  knife  laid  across  the  wound 
behind  the  caput  femoris,  and  a  short  flap  formed  by  cutting  along  the 


FlQ.  244.— Section  tlirough  left  thigh  in  the  upper  tliii-d.     1,  Superficial  femoral  artery,  vein,  and  saphena 
nerve.     2,  Deep  femoral  vessels ;  near  by  the  obturator  nerve  and  vessels.     3,  Sciatic  nerve  and  vessels. 

posterior  surface  of  the  femur  as  far  down  as  one  inch  beyond  the  gluteal 
fold  (Pig.  241). 

Of  these  various  procedures  at  the  hip,  the  first,  although  requiring 
more  time  for  its  performance,  should  be  preferred,  since  the  greatest  of 
all  dangers  in  this  operation — haemorrhage — is  practically  avoided.  In 
fat  subjects,  or  Avhere  the  muscular  development  is  very  great,  the  pro- 
cedure of  Mason  should  be  followed.  When  rapidity  of  execution  is 
essential,  the  fourth,  or  transfixion  method,  is  preferable. 


AMPUTATIOXS. 


159 


Fig.  245. — Transverse  section  of  left  thigh  through  lesser  trochanter.  Looking  from  below  -upward.  1, 
Saphenous  vein.  2,  Superficial  femoral  vein  and  artery.  3,  Profunda  femoral  vein  and  artery,  anterior 
crural  nerve  between  the  two  arteries.    4,  Obturator  nerve  and  artery.    5,  Sciatic  nerve  and  artery- 

NoTE. — The  following  summaries,  compiled  by  Dr.  F.  C.  Sheppard,  are  taken  from  Prof. 
Ashhui'st's  article  in  the  "  Eucyclopfedia  of  Surgery."  *  It  is  safe  to  assert  that  the  improved 
methods  of  hcemostasis  and  antisepsis  will  yield  a  lighter  rate  of  mortality,  ia  both  military  and 
civil  practice,  than  that  shown  by  a  study  of  these  tables. 


I.  Summary  of  Two  Hundred  and  Thirty-eight  Cases  of  Hip-joint  Amputation  in 
Military  Practice. 


NATURE   OF  OPEK.\TIOX 

Recovered. 

Died. 

tTndeter- 
mined. 

Total 

-Mortality 
per  cent. 

7 
4 
10 
4 
5 

89 
.59 
IT 
3 
39 

0 
0 
0 

0 

1 

96 
63 

27 

45 

92-7 

93-6 

62-9 

Reamputation  of  thigh-stump.  .  . . 
Not  stated 

42-8 
88-6 

Total  number  of  cases 

30 

•207 

1 

2:^8 

87-3 

William  Wood  &  Co.,  Xew  York,  1881. 


160 


A  TEXT-BOOK   ON  SURGERY. 


Fig.  246. — Section  through  the  left  hip.  Looliiug  from  below  upward.  Reduced  from  life  size.  1,  Fem- 
oral vein,  artery,  anti  crural  nerve  in  order  trom  within  outward.  2,  Great  sciatic  nerve,  artery,  and 
vein.     3,  Epigastric  vein,     i,  Vessels  to  acetabulum. 


II.  Summary  of  Seventy-one  Cases  of  Hip-joint  Amputation  for  Injury  in  Civil 

Practice. 


NATURE  or  OPERATION. 

Recovered. 

Died. 

Total. 

Mortality 
per  ceDt. 

6 
5 
5 
4 
4 

25 

7 
6 
1 
8 

31 
12 

11 

5 
12 

80-6 

Intermediate 

58-3 
54-5 

20-0 

66-6 

24 

47 

71 

66-1 

III.  Summary  of  Tico  Hundred  and  Seventy-six  Cases  of  Hip-joint  Amputation  for 

Disease. 


NATURE  OF  OPERATION. 

Recovered, 

Died. 

Undeter- 
mined. 

Total. 

Mortality 
per  cent. 

Amputation  of  entire  limb 

Reamputation  of  thigli-stiimp 

136 
20 

95 
10 

14 

1 

245 
31 

41-1 
33-3 

156 

105 

15 

276 

40-2 

AMPUTATIONS.  161 

IV.  Summary  of  Forty-eight  Cases  of  Hip-joint  Amputation  for  UnTcnown  Causes. 


Kecovered. 

Died. 

Undeter- 
mined. 

Total.        i        Mortality 
1        percent.* 

Number  of  cases 

10 

34 

i 

48         1         77-2 

V.  General  Summary  of  Six  Hundred  and  Thirty-three  Cases  of  Hip-joint  Ampu- 
tation for  all  Causes. 


NATURE  OF  CASE. 

Eecovered. 

Died. 

Undeter- 
mined. 

Total. 

Mortality 
per  cent. 

156 
54 
10 

105 

254 

34 

15 
1 

4 

276 
309 
48 

40-2 

82-4 

77-2 

Total 

220 

393 

20 

633 

64-1 

*  Undetermined  cases  omitted  in  computing  percentages. 


CHAPTER  IX. 

the  surgical  diseases,'  and  sukgeey  of  the  lymphatic  vessels, 
veins,  and  aeteeies. 

The  Lymphatic  System. — Lymphangitis. 

The  pathological  conditions  in  inflammation  of  the  lymphatic  vessels 
closely  resemble  those  of  the  veins,  with  which  they  are  intimately  asso- 
ciated. The  histology  of  the  two  systems  is  almost  identical.  One  essen- 
tial point  of  difl'erence,  and  one  which  has  a  pathological  significance,  is 
that  the  lymphatic  vessels  are  practically  closed  tubes,  since  at  varying 
intervals  in  their  route  to  the  center  each  trunk  breaks  up  into  small  and 
smaller  branches,  until  they  end  in  closed  capillaries  in  the  substance  of 
a  lymphatic  gland.  Although  it  is  not  yet  positively  proven  that  there 
is  no  direct  communication  between  the  afferent  and  efferent  vessels,  the 
weight  of  evidence  is  in  favor  of  the  theory  that  the  vessels  end  and  begin 
as  closed  tubes.  It  follows  that  whatever  of  septic  or  inflammatory 
matter  may  pass  into  these  vessels,  it  can  not  rapidly  enter  the  systemic 
circulation.  Each  lymphatic  gland  is  a  sieve  which  arrests  its  progress 
and  modifies  its  effect.  In  the  venous  system,  however,  there  is  no 
resistance  to  rapid  and  direct  systemic  infection.  We  conclude,  then,  on 
anatomical  grounds,  as  well  as  from  clinical  experience,  that  the  effects 
of  phlebitis  are  more  rapidly  felt,  and  in  general  more  disastrous,  than 
those  of  lymphangitis. 

LympJiangitis  means  an  inflammation  of  all  the  sti'uctures  which 
make  up  the  wall  of  a  lymph-carrying  vessel ;  the  endothelial  lining,  the 
muscular  and  connective  tissues,  are  involved.  Hyperfemia  and  thicken- 
ing occur,  with  or  without  coagulation  of  the  lymph  and  occlusion  of  the 
ducts.  As  in  other  inflammatory  processes,  the  native  and  wandering 
cells  undergo  proliferation,  and  form  in  the  extra-vascular  spaces  a  com- 
mon embryonic  tissue,  which,  under  certain  favorable  conditions,  may 
undergo  granular  metamorphosis  and  absorption  (resolution),  or,  if  the 
process  be  violent  and  the  tissues  of  a  low  order  of  vitality,  suppuration 
may  occur.  Lymphangitis  may  be  traumatic  in  origin,  or  result  as  a  part 
of  some  idiopathic  inflammation.  It  may  also  be  described  as  an  acute, 
subacute,  and  chronic  disease,  involving  the  superficial  or  deep  vessels, 
or  both. 

The  symptoms  of  acute  lymphangitis,  while  varying  in  intensity  pro- 
portionate to  the  virulence  of  the  cause  and  the  condition  of  the  tissues 


THE  LYMPHATIC   SYSTEM.  163 

affected,  are  the  same  in  the  essential  features  in  every  case.  Following 
an  inoculation  with  any  septic  matter,  within  a  few  hours  there  is  a 
sense  of  uneasiness  and  burning  in  the  immediate  vicinity  of  the  wound. 
Pain  is  not  usually  severe  until  the  swelling  is  well  marked.  At  the  end 
of  from  twenty-four  to  thirty-six  hours  the  injection  of  the  superficial 
vessels  which  lead  from  the  local  inflammation  toward  the  center  may  be 
recognized.  These  red  lines  give  a  peculiar  sensation  to  the  touch. 
While  the  outline  of  the  vessel  can  rarely  be  made  out  by  palpation, 
there  is  often  an  appreciable  thickening  and  tension  in  the  tissues  imme- 
diately over  and  around  it.  Pain  is  present  in  some  instances,  while  in 
others  even  direct  and  strong  pressure  causes  little  or  no  disturbance. 
When  the  nearest  gland  or  plexus  is  reached  by  the  inflammatory  j)ro- 
cess,  by  pressure  uj)on  these  a  sharp  sense  of  pain  is  experienced.  The 
febrile  movement,  which  may  ensue  within  twenty-four  hours,  though 
usually  not  well  marked  at  this  early  period,  is  generally  introduced  by 
a  chill  or  a  series  of  chilly  sensations,  characterized  by  pallor  and  the 
"  picked-goose  "  roughness  of  the  skin.  The  temperature  rises  rapidly 
above  the  normal,  and  may  reach  a  high  degree.  Nausea,  vomiting, 
delirium,  and  the  train  of  symptoms  which  accompany  septicaemia  may 
foUow;  but  this  is,  fortunately,  the  exception.  If  the  conditions  are 
unfavorable  to  the  progress  of  the  disease,  the  temperature  declines  gradu- 
ally, resolution  occurs,  and  the  symptoms  of  inflammation  disappear  in 
from  one  to  two  weeks. 

In  the  diagnosis  of  lympJtangitis  it  is  w^ell  to  bear  in  mind  that  in 
pTilebitls  the  lines  of  red  discoloration  are  wider  than  in  the  disease 
under  consideration,  that  there  is  a  more  general  condition  of  oedema, 
that  the  lines  of  inflammation  follow  well-known  and  appreciable  veins, 
that  these  veins  are  very  painful  to  pressure,  and  that  they  are  easily 
recognized  as  hard,  semi-elastic,  knotty  cords. 

In  erythema^  erysipelas^  and  dermatitis  the  discoloration  is  deep  and 
diffuse,  and  the  superficial  lymphangitis  which  exists  can  not  be  made 
out  in  the  general  staining.  It  is  evident,  however,  in  one  unfailing 
symptom — adenitis  in  the  glands  in  the  direct  route  of  the  vessels. 

The  treatment  is  local  and  general.  Cold  applications  are  preferable, 
if  cold  is  agreeable  to  the  patient.  Employ  the  ice  or  cold-water  bag,  or 
cold  cloths.  Heat  may  be  applied  in  a  similar  manner.  The  sense  of 
comfort  experienced  is  the  only  criterion  in  determining  the  employment 
of  these  agencies.  The  lead  and  o]Dium  wash  is  a  valuable  remedy. 
When  an  extremity  is  affected  it  should  be  kept  in  perfect  repose  and 
in  an  elevated  position.  If  suppuration  occurs,  the  pus  should  be  evacu- 
ated. If  cellulitis  and  great  tension  complicate  the  lymphangitis,  make 
free  parallel  incisions  to  obviate  threatened  strangulation.  The  consti- 
tutional remedies  look  to  the  regulation  of  the  alimentary  apparatus — 
quinia,  iron,  etc;,  and,  above  all,  pure  air  and  cheerful  surroundings. 

Subacute  and  chronic  lymphangitis  ai-e  associated  with  forms  of  gen- 
eral systemic  infection,  as  in  syphilis,  which  is  typical  of  the  subacute 
variety,  and  in  "Hodgkin's  disease"  and  the  so-caUed  scrofulous  dys- 
crasia,  which  are  chronic  forms  of  this  disease. 


164  A   TEXT-BOOK   ON   SURGERY. 

Adenitis,  or  inflammation  of  a  lymphatic  gland,  nsually  exists  with 
the  disease  just  considered,  or  it  may  be  independent  of  it. 

The  patJwlogical  changes  vary  as  the  process  is  acute,  subacute,  or 
clironic.  In  acute  adenitis  the  cells  of  the  reticulum  and  the  leucocytes 
proliferate  with  great  rapidity,  resulting  in  pressure  upon,  and  occlusion 
of,  the  periglandular  blood-vessels,  and  consequent  suppuration.  In  the 
subacute  and  chronic  forms  the  i^roliferation  is  confined  chiefly  to  the 
connective-tissue  cells  of  the  reticulum,  or  net-work  of  the  gland,  causing 
an  abnormal  thickening  of  the  stroma,  and  a  diminution  of  the  corpuscu- 
lar elements  of  the  gland. 

Acute  adenitis  may  result  from  a  blow,  from  excessive  muscular 
action,  or,  as  above  stated,  it  may  follow  an  acute  lymphangitis. 

The  symptoms  are  a  sense  of  soreness  and  tension,  sharp  throbbing 
pain,  increased  on  slight  pressure,  swelling,  and  redness  of  the  super- 
jacent skin.  The  suppuration  commences  in  the  center  of  the  gland, 
and  gradually  extends  until  the  tissues  around  are  involved.  The  con- 
stitutional symptoms  are  similar  to  those  given  in  lymj)hangitis.  If  the 
inflammatory  process  be  of  the  subacute  form,  the  enlargement  is  more 
gradual,  and  pain  and  the  other  symptoms  of  acute  adenitis  are  absent. 
Later  in  the  history  of  this  process  fatty  and  caseous  degenerations  may 
occur,  ending  in  resolution.  In  chronic  adenitis  the  tumors  are  more 
solid  and  firmer  to  the  touch,  since  the  enlargement  is  due  in  greater 
part  to  the  proliferation  and  hyperjilasia  of  the  connective-tissue  stroma. 

In  the  treatment  of  acute  adenitis  perfect  qiiiet  must  be  enforced. 
Local  applications  are  indicated  as  in  Ij^mphangitis.  If  suppuration  is 
evident,  early  incision  is  indicated.  Frequently  one  after  another  of  the 
glands  in  a  group  breaks  down  in  the  process  of  suppuration,  forming 
sinuses  which  undermine  the  neighboring  tissues,  when  it  is  necessary  to 
lay  each  abscess  open  freely  and  scrape  out  every  particle  of  diseased 
tissue  with  a  Volkmann's  spoon.  Thus  treated,  the  wound  should  be 
packed  with  sublimate  gauze,  and  treated  as  an  open  wound  through- 
out. If  recovery  does  not  follow,  a  thorough  dissection  should  remove 
the  diseased  glands. 

Chronic  enlargements  of  the  lymphatic  glands  require  chiefly  consti- 
tutional treatment.  Local  measures  may  be  deemed  advisable,  in  order 
to  protect  the  part  from  pressure.  Plasters  of  mercury,  belladonna,  or 
galbanum,  are  among  the  most  useful  remedies  of  this  kind.  Painting 
with  tincture  of  iodine  is  painful,  and  of  doubtful  benefit.  Among  con- 
stitutional remedies  the  protoiodide  of  mercury,  combined  with  tonics 
and  proper  alimentation,  will  in  general  prove  most  satisfactory.  Ex- 
tirpation is  indicated  when,  after  the  faithful  administration  of  consti- 
tutional remedies,  the  tumors  continue  to  increase.  In  malignant  and 
tubercular  adenitis,  operation  should  be  undertaken  at  once. 

Wounds  of  the  lymphatic  vessels  may  occur  in  common  with  solutions 
of  continuity  in  other  tissues.  The  escape  of  lymph,  and  occlusion  of  the 
vessels  involved,  back  to  the  first  collateral  branch,  is  the  rule,  as  with 
the  blood-vessels.  If  the  vessel  be  large,  as  when  the  deeper  channels  of 
the  leg  or  the  thoracic  duct  is  divided,  the  ligature  or  compression  of  the 


PHLEBITIS.  165 

distal  end  is  necessary  to  prevent  a  lymph  fistula.  It  has  been  demon- 
strated that  the  lymph  and  chyle  can  be  carried  into  the  circulation  by 
coEateral  routes,  after  occlusion  even  of  the  thoracic  duct. 

Varicosities  occur  at  times  in  the  lymphatic  vessels,  as  in  the  veins. 
The  causes  and  treatment  are  essentially  the  same.  As  a  result  of  ob- 
struction, in  some  instances,  cystic  dilatations  occur,  which,  according 
to  Bellamy,*  are  usually  found  in  the  tongue,  lips,  and  about  the  neck. 
Hydromata  of  the  neck  are  at  times  congenital.  In  their  structure  they 
are  trabeculated,  the  caverns  filled  with  lym]3h.  The  location  is  beneath 
the  occiput,  and  the  tumor  is  symmetrical,  the  cyst  of  each  side  of  the 
median  line  being  lined  with  lynij)hatic  endothelia. 

New  formations  (lymphomata)  of  lymphatic  vessels  occur  occasionally, 
and  blood-vessels  develoi)ing  in  these  give  rise  to  a  mixed  new  growth, 
known  as  lympho-angeioma. 


Phlebitis,  t 

Defi^'^ition  and  Moebid  Anatomy. — PhleMtis  means  an  inflamma- 
tion of  all  the  tissues  which  enter  into  the  formation  of  the  walls  of  a 
vein.  Endophlebitis,  mesoplilebitis,  and  periphlebitis  are  terms  used  to 
designate  the  inflammatory  process  involving  res]Dectively  the  internal, 
middle,  and  external  layers  of  the  venous  wall. 

The  progress  of  inflammation  in  the  tissues  of  veins  is  closely  analo- 
gous to  that  of  the  same  process  in  all  other  structures,  namely,  irrita- 
tion, liypergemia,  tumefaction,  infiltration  of  the  extra-vascular  sj)aces 
with  emigrant,  embryonic,  and  pus  cells ;  the  process  terminating  in 
cicatrization  (often  with  adhesions),  calcareous  degeneration,  suppuration, 
or  gangrene.  The  mode  of  termination  will  depend  upon  the  severity  of 
the  attack,  the  character  of  tlie  lesion,  and  the  i^ower  of  resistance  and 
recuperation  existing  in  the  tissues.  The  inflammatory  process  involves 
a  tubular  structure,  the  walls  of  which  are  composed  of  an  inner  layer 
{intinia),  made  up  of  flat,  polygonal  cells  (the  endothelia),  a  middle  layer 
chiefly  made  up  of  elastic  tissue,  and  an  outer  layer,  containing  elastic 
loops,  connective  tissue,  and  nnstriped  muscle.  Blood-vessels  and  nerves 
traverse  the  outer  and  middle  tunics,  following  the  bundles  of  connective 
tissue. 

The  cells  of  the  lining  membrane  are  smaller  than  the  arterial  endo- 
thelia, and  are  imbedded  in  a  fibrillated,  intercellular  substance  (Cornil 
and  Ranvier).  The  elastic  and  muscular  tissues  are  less  developed  than 
in  the  arteries  (Heitzmann).  These  are  so  irregularly  arranged  that  any 
division  into  middle  and  external  coats  is,  in  great  part,  artificial  and 
imaginary.      Moreover,  many  of  the  veins  contain  no  muscular  tissue, 

*  "  Enoyclopsedia  of  Surgery,"  vol.  iii,  p.  34,  Ashhurst.     "William  Wood  &  Co.,  1883. 

t  That  portion  of  this  chapter  between  pages  161  and  198  is  taken  from  my  article  in  the 
•'  International  Encyclopasdia  of  Surgery,"  edited  by  Prof.  John  Ashhurst,  Jr.,  M.  D. ;  pub- 
liahed  by  Messrs.  William  Wood  &  Co.,  of  N"ew  York  city,  for  whose  kind  permission  to  intro- 
duce it  in  this  book  in  its  original  form  the  author  begs  to  make  his  sincere  acknowledgment. 


166  A   TEXT-BOOK   ON   SURGERY. 

while  their  connective  tissue  varies  in  quantity  in  different  parts  of  the 
body.  The  sinuses  of  the  dura  mater,  the  veins  in  bones,  and  those  of 
the  retina,  have  no  muscular  fibers,  while  the  jugulars,  subclavians,  and 
vense  cavge  have  a  relatively  small  quantity,  or  are  entirely  devoid  of  this 
tissue.  Again,  the  arrangement  of  the  muscular  tissue  differs  in  different 
veins.  The  inferior  vena  cava  and  the  portal  and  renal  vein^  have  an 
inner,  circular,  and  an  external,  longitudinal  layer,  while  the  femoral  and 
popliteal  veins  have  the  longitudinal  libers  more  internal.  This  tissue  is 
still  more  complicated  in  the  saphenous  veins,  where  the  internal  layers 
are  arranged  longitudinally,  with  a  number  of  alternating,  or  transverse 
and  longitudinal,  layers  placed  externally  to  these. 

The  elastic  layer  begins  immediately  external  to  the  basement  sub- 
stance which  supports  the  endothelial  layer,  and  is  here  somewhat  iso- 
lated and  well  defined ;  but  from  the  external  surface  of  this  central, 
elastic  lamina  springs  a  net-work  of  elastic  fibers,  through  the  loojis  and 
in  the  meshes  of  which  are  woven  the  muscular  and  connective-tissue 
fibers. 

The  vasa  vasorum  follow  the  connective-tissue  bundles  in  their  distri- 
bution to  the  tissues  of  the  wall  down  to  the  elastic  layer.  Nerves  from 
the  sympathetic  system  have  been  demonstrated  in  the  larger  veins. 

The  valves  are  delicate  reduplications  of  the  internal  coat,  having  a 
well-defined,  elastic  reticulum,  especially  on  their  distal  or  convex  sur- 
face (Heitzmann),  and  muscula:r  fibers  at  the  point  of  attachment  to  the 
venous  wall. 

The  vascular  area — the  outer  and  middle  layers — is  first  concerned  in 
the  inflammatory  process.  The  endothelial  tunic,  as  a  result  of  these 
structural  changes,  is  subsequently  involved  in  the  process.  It  then 
appears  cloudy,  thickened,  and  rough,  and  may  become  separated  in 
shreds.     (Frey.) 

In  the  vascular  area,  during  the  earlier  stages,  the  caj)illaries  of  the 
vasa  vasorum  become  swollen,  the  white  corpuscles  migrate  into  the 
extra- vascular  spaces,  and  the  normal  connective-tissue  cells  are  stimu- 
lated into  rapid  proliferation,  resulting  in  a. thickening  of  the  wall,  due 
to  the  presence  of  these  embryonic  cells,  and  the  excessive  hypersemia. 
As  in  arteritis,  the  vitality  of  the  endothelial  tunic  becomes  impaired, 
and  it  is  more  or  less  projected  into  the  cavity  of  the  vein,  the  endothelia 
undergoing  rapid  proliferation.  After  a  few  days,  granulation- buds  push 
out  from  this  embryonic  tissue  of  the  endothelia,  and  new  capillaries  are 
developed  in  the  granulation  -  masses,  anastomosing  and  becoming  a 
part  of  the  circulation  of  the  vasa  vasorum,  as  well  as  leading  into  the 
coagulum  which  occupies  the  caliber  of  the  vein. 

At  the  point  of  contact  of  the  outer  surface  of  the  thickened  endo- 
thelial layer  with  the  internal  surface  of  the  middle  (elastic)  layer,  large 
sinuses  are  developed,  which  receive  the  blood  from  the  capillaries  of  the 
middle  tunic.  These  sinuses  are  lined  with  an  endothelial  layer,  which 
rests  upon  the  contiguous  connective  tissue.  From  these  large  vessels 
fine  capillaries  are  given  off,  which  permeate  the  thickened  internal  layer, 
and  some  of  which  pass  into  the  organizing  coagulum. 


PHLEBITIS.  167 

When  a  thrombus,  caused  by  the  sudden  coagulation  of  the  blood  in 
a  vein,  is  examined  in  its  recent  state,  it  is  foimd  to  be  composed  of  suc- 
cessive laminae  of  fibrin  and  corj)uscles,  and  the  more  recent  of  these 
lamiufe  are  external.  When  the  vein  is  first  occluded  by  this  sudden 
coagulation  of  the  blood,  the  pressure  from  behind  is  so  great  that  the 
coagulum  is  compressed  toward  its  center,  while  the  current,  more  and 
more  imiDeded  in  its  j)rogress,  flows  between  the  perijDhery  of  the  clot  and 
the  inner  surface  of  the  vessel,  adding,  layer  by  layer,  fresh  deposits  of 
coagulation  upon  the  thrombus.  A  microscopical  examination  of  such 
thrombi  reveals  a  vast  number  of  white  corpuscles  in  various  stages  of 
fatty  degeneration,  with  layers  of  fibrin  intervening. 

Experiments  have  shown  that  not  only  does  the  inflammatory  process, 
by  reason  of  its  invasion  of  the  intima,  produce  changes  in  the  blood 
which  lead  to  stasis,  but  that  there  is  also  a  dangerous  endosmosis  of 
septic  matter,  which  is  swept  along  toward  the  heart  and  lodged  in  the 
capillaries  of  the  various  organs  (emboli),  producing  infarctions,  abscesses, 
and,  almost  invariably,  irreparable  damage.  The  adhesion  of  the  intima, 
and  the  formation  of  a  fibrinous  clot — which  may  completely  occlude  the 
vessel  {occlusion  tlirovibus),  or  may  merely  plaster  over  the  endothelial 
tunic  {peripheral  thrombus) — are  efforts  toward  prevention  of  this  endos- 
mosis. 

The  process  of  repair  in  tissues  cajjable  of  successful  resistance,  in 
venous  inflammation,  is  one  of  organization  of  the  embryonic  cells,  fibril- 
lation, and  contraction,  resulting  in  partial  or  comi^lete  occlusion.  In 
tissues  of  low  and  impaired  vitality,  the  progress  of  the  inflammation  is 
rapidly  toward  suppuration,  usually  terminating  in  septic  fever  and 
death.  Microscopical  sections  from  such  specimens  of  phlebitis  show 
that  the  leucocytes  and  embryonic  cells  have  undergone  retrogressive 
changes,  and  that  the  tissues  are  infiltrated  with  pus  corpuscles.  Gan- 
grenous sj^ots  are  not  infrequent,  often  opening  into  the  caliber  of  the 
vessel,  and  allowing  the  influx  of  septic  products,  or  the  efilux  of  blood. 

Since  phlebitis  is  a  frequent  cause  of  thrombosis,  and  since  venous 
thrombosis  is  the  most  frequent  form  of  intra-vascular  coagulation,  a 
consideration  of  the  pathogeny  and  pathology  of  this  process  must  natu- 
rally find  a  place  here.  Virchow  has  endeavored  to  show  that  primitive 
phlebitis  is  extremely  rare,  and  that,  when  a  clot  is  produced  in  a  vein 
which  is  inflamed,  the  coagulation  has  more  often  preceded  than  followed 
the  inflammation.  Cornil  and  Ranvier,  from  whom  the  above  account  is 
taken,  do  not  accept  this  theory. 

Fibrin,  the  immediate  factor  in  coagulation  of  the  blood,  does  not 
exist  as  such  in  the  normal  condition  of  this  fluid.  Under  healthful  con- 
ditions, the  blood  would  circulate  always  without  any  deposit  of  fibrillated 
fibrin  in  the  economy.  According  to  Denis,  the  normal  jjlasma  of  the 
blood  can  be  separated  into  a  semi-solid  substance,  plasmine,  and  a  liquid, 
serine.  Plasmine  is  further  separable  into  fibrin  and  metalbumen,  and 
it  is  held  that  the  coagulation  of  the  blood  is  due  to  the  conversion  of 
plasmine  into  fibrin.  Foster  holds  that  coagulation  is  the  result  of  the 
interaction  of  two  bodies,  paraglobulin  and  fibrinogen,  brought  about 


168  A  TEXT-BOOK   ON  SURGERY. 

by  the  agency  of  a  third  body,  fibrin-ferment.  A.  Schmidt  has  earned 
experimentation  further,  and  is  led  to  believe  that  paraglobiilin  and 
fibrin-ferment  both  originate  in  the  whits  blood-corpuscles.  This  theory 
is  exceedingly  seductive,  and  it  can  not  be  denied  that  actual  pathology 
proves  that  around  and  within  inflammatory  areas  where  white  blood- 
corpuscles  are  most  abundant,  coagulation  and  fibrillation  are  more  apt  to 
occur,  and  a  study  of  thrombi,  which  have  been  gradually  formed,  reveals 
alternating  layers  of  white  corpuscles  and  fibrillated  fibrin.    (Gfreen.) 

What  may  be  the  principle  in  the  blood  which  is  the  factor  of  coagula- 
tion, or  what  reaction  it  may  be  which  precipitates  the  fibrin,  we  can  not 
in  the  present  conditon  of  science  positively  assert.  The  facts,  however, 
"point  to  the  conclusion  that  when  blood  is  contained  in  healthy,  living 
blood-vessels,  a  certain  relation  or  equilibrium  exists  between  the  blood 
and  the  containing  vessels,  of  such  a  nature  that,  as  long  as  this 
equilibrium  is  maintained,  the  blood  remains  fluid ;  but  when  this 
equilibrium  is  disturbed  by  events  in  the  blood  or  blood-vessels  (or  by 
the  removal  of  the  blood),  it  undergoes  changes  which  result  in  coagu- 
lation."   (Foster.) 

So  delicate  is  the  sensibility  of  the  blood  to  mechanical  irritation  or 
hindrance  in  its  flow,  that  the  slightest  injury  or  roughening  of  the 
endothelial  lining  membrane  may  produce  a  deposit  of  fibrillated  fibrin. 
A  delicate  needle,  or"  wire,  or  thread,  thrust  into  the  lumen  of  a  healthy 
vessel,  precipitates  coagulation  upon  the  foreign  body.  The  white  cor- 
puscles are  found  clustered  in  great  numbers  on  the  foreign  body,  and, 
when  the  mass  is  examined  with  the  microscope,  the  corpuscles  seem  to 
serve  as  starting-points  for  the  development  of  fibrin.     (Reichert.) 

Causes  and  Clinical  History  of  Phlebitis. — Phlebitis  has  been 
termed  traumatic  and  idiopathic,  and  the  latter  term  has  been  applied 
indiscriminately  to  all  forms  of  phlebitis  not  directly  due  to  an  apj)re- 
ciable  lesion. 

Idiopathic  phlebitis  is  comparatively  a  rare  affection  (Virchow).  It 
may  occur  without  a  traumatism,  as  from  exposure  to  cold,  or  as  a  sequel 
to  fevers  and  varicosities  (Hamilton).  It  may  occur  as  a  complication  of 
syphilis  (Hutchinson),  or  as  a  result  of  the  gouty  diathesis  (Paget).  From 
whatever  cause  it  may  proceed,  idiopathic  phlebitis  usually  affects  the 
veins  of  the  lower  extremities. 

Traumatic  phlebitis  may  be  caused  by  a  partial  or  complete  solution 
of  continuity  of  the  venous  walls,  by  contiguity  of  inflamed  tissues,  or  by 
violent  muscular  action  and  pressure. 

The  inflammation  of  the  uterine  sinuses  during  and  after  parturition, 
which  Cornil  and  Ranvier  style  "la  phlebite  spontanee,"  is  really  a  fonn 
of  traumatic  phlebitis,  due  to  the  irritation  resulting  from  pressure  and 
muscular  action. 

Phlebitis  has  been  described  as  acute  and  chronic  (Gross) ;  adhesive 
and  suppurative  (Bryant) ;  gouty  and  diffuse  (Hamilton).  These  terms 
but  express  varying  conditions  of  one  pathological  process,  and  whether 
this  inflammatory  process  shall  result  in  adhesion  or  suppuration,  shall 
become  diffused,  or  shall  assume  a  chronic  form,  will  depend  solely  upon 


PHLEBITIS.  169 

the  character  and  cause  of  the  disease,  and  iipon  the  capacity  of  the 
tissues  to  resist  its  progress. 

1.  Idiopathic  Phlebitis.  1.  SypTiiliUc  PlileMtis.—Mv.  Hutchinson 
has  called  attention  to  the  very  few  cases  of  syphilitic  phlebitis  which 
have  been  recorded,  and  yet  he  says  that  most  surgeons  are  familiar  with 
the  fact  that  inflammations  around  varices,  and  even  about  otherwise 
healthy  veins,  are  not  infrequent  in  syphilitic  subjects.*  Mr.  Hutchin- 
son further  says:  "I  think  also  that  I  have  seen  several  cases  in  which 
the  thrombosis  and  phlebitis  were  attended  by  other  conditions  sufficiently 
peculiar  to  justify  a  belief  that  they  were  of  specific  origin.  In  some 
there  has  been  great  excess  of  inflammation,  a  large  hard  mass  fonning 
in  the  cellular  tissue,  and  threatening  to  slough,  much  as  subcutaneous 
gummata  often  do.  These  cases  are  much  benefited  by  the  iodide  of  po- 
tassium, so  far  as  prevention  of  sloughing  is  concerned,  but  the  thrombotic 
plugging  remains."  f 

2.  Gouty  Phlebitis.  — Subjects  (says  Mr.  Bryant)  who  are  gouty  from 
hereditary  or  acquired  causes  are  liable  to  phlebitis.  Paget  has  described 
the  affection  in  his  "Clinical  Lectures,"  and  Mr.  Gay  has  written  upon 
it.  In  such  cases  the  phlebitis  may  have  no  intrinsic  characters  by  which 
to  distinguish  it,  yet  not  rarely  it  has  peculiar  marks,  especially  in  its 
symmetry,  apparent  metastases,  and  frequent  recurrences.  Like  other 
forms,  it  is  more  common  in  the  lower  than  in  the  upper  extremities,  yet 
it  may  be  found  anywhere.  It  affects  the  supei-ficial  rather  than  the 
deej)  veins,  and  often  occurs  in  patches,  aifecting  on  one  day,  for  example, 
a  short  piece  of  the  saphenous  vein,  and  the  next  another  portion  of  the 
same  vein,  some  other  distant  vein,  or  a  corresponding  piece  of  the  oppo- 
site vein. 

The  inflamed  portions  of  the  vein  usually  feel  hard  and  are  painful  to 
the  touch.  The  soft  parts  covering  the  vein  become  slightly  thickened, 
and  often  have  a  dusky,  reddish  tint.  When  the  deep  veins  are  involved, 
cedema  appears,  with  the  well-recognized  results  of  obstruction  :  the  limb 
becomes  big,  clumsy,  featureless,  heavy,  and  stiff ;  its  skin  is  cool,  and 
may  be  pale,  but  more  often  has  a  sKghtly  livid  tint,  which  may  be  recog- 
nized by  comparison  with  the  other  limb  ;  and  it  has  mottlings  from 
small  cutaneous  veins,  visibly  distended.  The  limb,  thus  enlarged,  feels 
Cfidematous  throughout,  but  firm  and  tight-skinned,  not  yielding  easily 
to  pressure,  and  not  pitting  very  deeply. 

The  constitutional  symptoms  associated  with  this  affection  vary  from 
some  slight  febiile  condition  to  those  met  with  in  acute  gout.  Complete 
recovery  may  take  place  in  this  as  in  other  forms  of  phlebitis,  the  veins 
becoming  pervious  in  some  cases  and  obstructed  in  others.  The  risks  of 
embolism  are  also  the  same.     (Bryant.) 

3.  Acute  IdiopatTiic  Phlehitis  (not  gouty  or  syphilitic). — This  form 
of  venous  inflammation — caused,  as  has  been  said,  by  exposure  to  cold, 
due  to  the  presence  of  a  varicosity,  or  coming  in  the  course  of  a  severe 
febrile  attack — may  involve  one  or  more  veins.     The  disease  travels  along 

*  J.  H.  C.  Simes  and  J.  William  White,  in  Cornil  on  Syphilis.  +  Ibid. 


170  A  TEXT-BOOK   ON   SURGERY. 

the  vessels  in  the  direction  of  the  heart.  The  veins  become  swollen,  and 
are  hard  to  the  touch,  resembling  the  normal  veins  when  the  return  cir- 
culation is  momentarily  arrested,  though  more  cord-like  in  feel  and  less 
elastic.  Their  course  can  be  traced  by  the  dull-red  color  of  the  skin 
immediately  over  the  diseased  vessels.  Pain  is  generally  constant,  and 
is  rendered  more  acute  by  pressure.  The  oedema  of  the  parts  on  the 
distal  side  of  the  lesion  is  commensurate  with  the  obstruction  to  the 
return  circulation  caused  by  the  inflammatory  process.  The  febrile 
movement  varies  with  the  violence  of  the  attack,  the  rapidity  of  its 
progress,  the  intensity  of  the  inflammation,  and  the  capacity  of  the 
tissues  to  resist  invasion.  In  the  severe  forms,  the  cKnical  history  is 
similar  to  that  of  traumatic  phlebitis,  which  will  be  fully  described 
hereafter.  Idiopathic  phlebitis  is  not  as  dangerous  to  life  as  the  trau- 
matic variety.  It  may  run  a  short  course,  and  the  patient  recover 
promptly,  or  it  may  assume  a  subacute  or  chronic  form,  and  remain 
indefinitely. 

II.  Teattmatio  Phlebitis. — When  a  vein  is  injured,  inflammation 
wiU  result,  if  the  vessel  is  penetrated  to  its  cavity,  or  suffers  a  solution 
of  continuity  in  any  portion  of  its  wall.  Examples  of  traumatic  jDhlebitis, 
resulting  in  thrombosis  and  occlusion  of  the  popliteal  vein,  are  known 
to  have  been  caused  by  prolonged  forced  flexion  of  the  leg  on  the  thigh. 
The  simplest  form  of  traumatic  phlebitis  is  that  resulting  from  the  opera- 
tion of  venesection.  No  matter  what  may  be  the  character  of  the  trau- 
matism, the  iDathological  process  is  the  same.  The  mode  of  termination 
of  this  process  will  depend  upon  the  extent  and  severity  of  the  lesion,  and 
upon  the  recuperative  powers  of  the  tissues  involved.  Traumatic  jDhlebitis 
extends  from  the  original  lesion  along  the  vessels  in  the  direction  of  the 
heart.  In  the  deeper  veins  it  is  with  difficulty  recognized  in  the  earlier 
stages.  The  course  of  the  inflammation  is  marked  by  a  diill,  coppery-red 
staining.  Pain  is  invariably  present,  and  upon  pressure  is  acute.  In 
severe  cases  the  tumefaction  spreads  from  the  vessels  to  the  surrounding 
tissues.  CEdema  of  the  parts  on  the  distal  side  of  the  lesion  will  occur  in 
a  degree  commensurate  With  the  interference  with  the  return  circulation. 
The  febrile  movement  is  that  of  septic  fever :  chills  or  rigors,  flushes  of 
heat  ending  in  cold  and  exhausting  sweats,  sleeplessness,  hectic,  anxious 
expression,  and  often  the  "pysemic  breath."  The  rectal  temperature  is 
variable  and  high ;  the  pulse  is  thready  and  rapid,  reaching  in  some 
instances  160.  Sudden  and  dangerous  symptoms  may  arise  in  the  course 
of  the  disease,  when  particles  from  the  venous  thrombi  are  carried  toward 
the  heart.  These  usually  lodge  in  the  lungs,  giving  rise  to  sudden  pul- 
monary complications,  the  result  of  infarction.  The  liver,  in  phlebitis  of 
the  veins  which  go  into  the  portal  circulation,  is  frequently  the  seat  of 
embolic  abscess.  Hemorrhage  from  perforation  of  the  venoiis  wall,  by 
ulceration  or  gangrene,  is  another  source  of  danger  in  severe  cases  of 
phlebitis. 

Treatment  of  Phlebitis. — Positive  and  complete  rest  is  the  first  great 
essential  in  the  treatment  of  phlebitis.  Manipulation  or  movement  is 
dangerous,  since  interference  wiU  not  only  exaggerate  the  inflammatory 


ARTERITIS.  171 

process,  but  may  possibly  cause  the  separation  of  thrombi  and  produce 
iniinite  harm  ia  remote  organs.  If  the  disease  should  assume  the  sup- 
purative form,  the  inflammation  being  diffase  and  the  oedema  severe,  free 
incisions  parallel  to  the  veins  should  be  made  in  order  to  secure  drainacre. 
A  wet  dressing  should  be  applied,  and  the  wounds  frequently  irrigated 
with  1  to  lO.OOU  sublimate  sohition  until  the  more  urgent  symptoms  have 
disappeared.  Quinia  is  indicated,  not  only  on  account  of  its  we^-kno^vn 
tonic  and  antifebrile  properties — although  not  strictly  antiseptic  in  its 
action,  the  bacteria  of  septic  fluids  resisting  its  action  to  a  great  extent 
( Bartholowj — but  because  it  exercises  an  inhibitory  influence  upon  the 
emigrant  corpuscles  (Binz  i,  important  factors,  as  Conheim  has  sho-nm,  in 
the  inflammatory  process.  The  use  of  iron,  carefud  feeding,  and  a  free 
supply  of  pure  air,  will  complete  the  constitutional  ti'eatment.  If  an 
extremity  is  involved  it  should  be  slightly  elevated  to  favor  the  return 
circulation. 

Aeteeitis. 

Arteritis  is  a  term  applied  to  an  inflammatory  process  which  involves 
the  entire  thickness  of  the  arterial  wall.  TNTien  the  inflammatory  change 
is  confined  to  the  inner  coat,  or  intima,  it  is  designated  as  endarteritis  : 
when  to  the  outer  coat,  or  adventitia,  as  periarteritis ;  and  when  to  the 
middle  coat,  or  media,  as  rnesa/rteritis. 

Endarteritis,  which  does  not  rapidly  disappear  soon  after  its  inception, 
is  apt  to  result  in  lesions  of  the  media  and  adventitia,  and  in  like  man- 
ner a  lesion  of  the  external  tunic  Avill  in  all  probability  involve,  by  the 
extension  of  the  morbid  process,  rhe  other  coats. 

There  are,  however,  certaia  weU-defined,  circumscribed  lesions  of  the 
separate  tunics;  Endarteritis  is.  as  an  isolated  lesion,  capable  of  demon- 
stration. We  shall  see  that  a  superficial  inflammation  of  the  endotheUa, 
with  its  resultant  fatty  degeneration,  is  not  infrequent.  Again,  mesar- 
teritis  exists  as  a  primary  and  separate  inflammation,  for  primary  calci- 
flcation  (denied  by  some  pathologists),  which  is  strictly  a  disease  of  the 
tunica  media,  precipitates  an  inflammation  in  this  middle  tunic.  And 
since  atheroma  and  other  arterial  lesions  are  due  to  interference  with  the 
blood-supply  through  the  vasa  vasorum,  or  to  defect  in  the  quality  of 
the  blood  distributed  to  the  adventitia  through  which  the  vessels  ramify, 
we  must  recognize  a  periarteritis  as  the  initial  stage  of  this  lesion. 

Inflammation  may  be  established  in  any  or  all  parts  of  the  arterial 
system.  One  form  of  arteritis  will  involve  the  larger  ti'unks,  while 
another  will  pass  these  without  molestation,  and  establish  itself  in  the 
distant  arterioles.  Simple  endarteritis  is  most  apt  to  occur  in  the  aorta 
and  arteries  of  the  second  mag-nitude,  while  syphilitic  arteritis,  the  most 
marked  feature  of  which  is  an  endarteritis,  rarely  attacks  the  larger 
trunks,  chiefly  confining  itself  to  the  more  or  less  complete  occlusion  of 
the  small  and  smallest  arteries. 

The  internal  coat  of  the  larger  arteries  is  composed  of  two  parts :  1. 
An  endothelial  lining  membrane,  consisting  of  a  single  layer  of  flat,  po- 


172  A  TEXT-BOOK   ON  SURGERY. 

lygonal,  nucleated  cells,  slightly  elongated  in  the  axis  of  the  vessel ;  in 
edge  view,  these  cells  aj^pear  spindle-shaped,  on  account  of  the  elevation 
of  the  nucleus  at  its  center  (Heitzmann) ;  2.  A  subendothelial  layer  of 
flattened,  nucleated,  anastomosing  cells  resting  in  a  fibrillated  basement 
substance,  the  direction  of  the  fibrillse  being  generally  parallel  with  the 
long  axis  of  the  artery  (Cornil  and  Ranvier).  In  the  smaller  arteries  this 
layer  is  exceedingly  fine,  while  in  the  aorta  it  is  comparatively  thick, 
being  composed  of  two  distinct  layers.  Here  the  internal  of  these  two 
layers  is  longitudinal,  the  external  transverse  in  direction.  The  middle 
coat  in  the  larger  arteries,  such  as  the  aorta  and  carotids,  is  composed  of 
elastic  laminae  and  of  fibers,  forming  by  their  anastomoses  a  continuous 
system,  and  holding  in  the  meshes  of  their  loops  the  muscular  tissue, 
transverse  in  its  direction,  and  a  relatively  small  amount  of  connective 
tissue  (Cornil  and  Ranvier).  According  to  C.  Toldt,  the  muscle-fibers  of 
the  middle  coat  are  wanting  in  the  initial  portion  of  the  aorta,  in  the  pul- 
monary artery,  and  in  the  arterioles  of  the  retina.  In  the  descending 
aorta,  the  common  iliac,  and  the  popliteal,  small  bundles  in  an  oblique 
or  longitudinal  direction  are  interspersed  between  the  circular  ones,  and 
in  other  arteries,  such  as  the  renal  and  spermatic,  at  the  inner  boundary 
of  the  muscular  coat,  scanty  longitudinal  bundles  occur,  which  by  some 
are  considered  to  belong  tq  the  inner  coat.  At  times,  in  the  correspond- 
ing arteries  of  different  persons,  differences  are  observed  in  the  distribu- 
tion of  the  muscles  of  the  middle  coat  (Heitzmann).  On  the  side  nearest 
the  inner  coat  the  middle  tunic  is  limited  by  a  denser  and  more  defined 
elastic  lamina,  which  shows,  however,  on  transverse  section,  a  festooned 
appearance — very  important  in  the  study  of  the  pathology  of  arteritis — 
and  is  named  the  internal  layer  of  the  elastic  coat.  Upon  the  side  of  the 
tunica  media  nearest  the  external  coat  the  elastic  fibers  pass  outward, 
interlacing  freely  with  the  connective  tissue  of  the  adventitia.  In  the 
femoral,  brachial,  and  other  arteries  of  middle  size,  the  middle  coat  pos- 
sesses only  one  layer,  namely,  the  internal  elastic.  The  miascular  fibers 
are  transverse  in  direction,  and  form  themselves  into  flattened  bundles, 
separated  by  connective-tissue  bundles  and  by  elastic  fibrillse,  which  are 
continuous  on  the  one  hand  with  the  inner,  elastic  layer,  and  on  the  other 
with  the  elastic  net- work  interwoven  with  the  adventitia.  There  are  no 
vessels  in  the  middle  and  internal  coats.  In  the  external  coat  are  found 
arteries,  capillaries,  veins,  lymphatics,  and  nerves. 

The  small  arteries  have  a  middle  coat,  formed  of  involuntary  miiscle- 
cells,  so  interwoven  that  they  form  a  continuous  membrane  (Cornil  and 
Ranvier).  C.  Heitzmann  *  describes  this  layer  as  seemingly  twined  round 
the  artery.  The  adventitia  here  is  composed  of  small  bundles  of  con- 
nective tissue,  arranged  in  the  main  in  a  longitudinal  direction. 

Pathogeny  of  Arteritis. — The  causes  of  arteritis  are  numerous.  The 
most  frequently  recognized  form  is  that  resulting  from  injury,  and  known 
as  traumatic  arteritis.  The  pathogeny  of  the  non-traumatic  (idiopatTiic^ 
arteritis  embraces  every  form  of  dyscrasia.     It  follows  in  the  train  of 

*  "Microscopical  Morphology  of  the  Animal  Body  in  Health  and  Disease,"  New  York,  1883. 


ARTERITIS. 


173 


syphilis,  rlieumatism,.  gout,  alcoholism,  and  nephritis  with  great  regu- 
larity, and  may  occur  as  a  result  of  any  morbid  process  which  poisons 
the  blood  or  impairs  its  nutritive  qualities.  These  varieties  will  be  con- 
sidered under  special  headings. 

The  sequelae  of  arteritis,  as  far  as  the  arteries  are  concerned,  may  be 
fatty  infiltration  and  degeneration,  atheroma,  secondary  calcification, 
occlusion,  dilatation,  aneurism,  supjDuration,  ulceration,  and  rupture. 
Remotely,  partial  or  complete  loss  of  function  of  the  organs  beyond  the 
lesion,  and  partial  or  general  necrosis  or  necrobiosis.  I  shall  consider 
arteritis  under  two  great  heads,  traumatic  and  non-traumatic,  subdivid- 
ing these  as  their  i^athogeny  or  pathology  may  justify  in  the  considera- 
tion of  each  separate  type. 

I.  Traumatic  Arteritis. — Arteritis  may  result  from  violence,  either 
from  without  or  from  within.  External  violence  wUl  produce  an  inflam- 
mation of  all  the  tunics  of  an  arteiy,  in  the  majority  of  cases,  while  vio- 
lence from  within  is  more  apt  to  cause  an  endarteritis.  Arteritis  from 
external  causes  is  never  an  uncomplicated  injury.  The  perivascular 
tissue  is  of  necessity  involved  in  the  inflammatory  process.  In  the  arte- 
ritis resulting  from  deligation  of  an  artery,  from  the  forcible  comi)ression 
of  a  vessel,  as  in  bending  the  knee,  from  the  pressure  of  a  tumor,  or  from 
a  blow  in  the  track  of  the  artery,  there  is  always  an  accomjpanying  inflam- 
mation of  the  surrounding,  injured  tissues. 

The  pathology  of  traumatic  arteritis  does-not  differ  greatly  from  the  in- 
flammatory process  which 
occurs  in  other  vascular 
tissues.  Immediately  fol- 
lowing the  injury  there  is 
a  marked  increase  in  the 
vascularity  of  the  adven- 
titia.  The  vasa  vasorum 
become  swollen,  the  white 
blood-corpuscles  crowd  in- 
to the  ca]3i]laries,  and  pass 
into  the  extra  -  vascular 
spaces,  while  a  rapid  pro- 
liferation of  the  normal 
cell-elements  of  the  arte- 
rial tunics  takes  place. 
The  connective- tissue  cells 
of  theadventitia,  the  white 
corpuscles,  and  the  flat 
and  polar  cells  of  the  in- 
tima,  all  take  part  in  the 
morbid  process.  The  walls 
of  the  vessel  become  ab- 
normally thickened,  while, 
owing  to  the  projection  in- 
ward  of  the   intima,  the 


Fio.  24T. — Traumatic  arteritis.  Transverse  section  of  the  carotid 
artery  of  a  dog,  fifteen  days  after  ligature  •  S,  granulation  buds 
formed  from  projection  of  tlie  intima.  In  tne  center  of  the 
figure  one  of  these  buds  has  been  completely  cut  across ;  wi, 
portion  of  the  media  modified  by  the  inflammatory  process ; 
«,  advcntitia ;  V  f",  vessels  out  across,  one  of  whicli  is  newly- 
formed  in  the  intima.  Magnified  15  diameters.  (After  Cornil 
and  Kauvier.) 


174 


A  TEXT-BOOK  ON   SURGERY. 


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caliber  of  the  vessel  is  diminished.     If  the  intima  has  been  broken  or 
bruised  by  the  injury,  the  encroachment  upon  the  caliber  of  the  vessel 

will  be  more  rapid,  for, 
^^^^s'^^^'j^   -  in  addition  to  the  mass 

of  embryonic  tissue 
pushing  into  the  lumen 
of  the  artery,  there  will 
be  a  deposit  of  fibrin 
upon  the  roughened 
and  projecting  inter- 
nal tunic.  The  white 
corpuscles  in  the  pass- 
ing blood-current  ad- 
here to  the  inflamed 
surface,  and  undergo  a 
change  which  causes  a 
liberation  of  the  fibri- 
no-plastic  matter  which 
they  contain,  and  a 
deposit  of  fibriUated 
fibrin.  This  coagulum 
is  found  to  consist  of 
alternate  layers  of  leu- 
cocytes and  fibrin.  In 
the  mean  time,  if  the 
inflammation  be  not  so 
severe  that  rapid  necrosis  occurs  from  the  sudden  arrest  of  the  blood- 
supply  through  the  vasa  vasorum,  new-formed  capillaries  push  through 
the  mass  of  embryonic  cells,  into  the  "granulation  buds"  which  j^roject 
into  the  lumen  of  the  vessel  (Fig.  247). 

This  form  of  arteritis  may  result  in  permanent  occlusion  of  the  vessel 
{endarteritis  obliterans)^  or  the  function  of  the  artery  may  be  restored. 
If  occlusion  occurs,  it  results  from  the  organization  of  the  embryonic  cells 
into  a  new  tissue  which  undergoes  fibrillation  and  contraction  (a  process 
of  cicatrization)  to  such  an  extent  that  the  new-formed  capillaries  are 
more  or  less  occluded,  and  the  artery  shrinks  to  become  a  fibrous  cord 
(Fig.  248).  Or  the  coagulum  may  undergo  fatty  degeneration,  and  be 
swept  away  with  the  current  of  blood,  the  vessel  remaining  pervious  and 
bearing  but  little  trace  of  the  inflammatory  process  through  which  it  has 
passed.  The  microscopical  appearances  of  a  localized  traumatic  arteritis 
are  typically  represented  in  Fig.  249,  wdiich  is  co]Died  from  a  section  made 
from  the  carotid  of  a  horse.  The  animal  was  in  a  healthy  condition  at 
the  time  of  the  operation.  I  tied  the  artery  with  a  broad  carbolized  liga- 
ture, the  sciatic  nerve  of  a  calf.  In  the  fifth  week  the  animal  was  killed. 
The  artery  was  pervious.  The  location  of  the  ligature  was  easily  recog- 
nized by  the  peculiar,  whitish,  pearly  appearance  of  the  intima  at  the 
point  of  tying,  where  it  was  slightly  elevated.  The  adventitia  did  not 
show  any  changes  to  the  naked  eye.     The  ligature  had  evidently  slipped 


Fig.  248. — Endarteritis  obliterans,  not  syphilitic.  Transverse  section 
of  the  basilar;  a,  muscul.iV  layer ;  e,  elastic  layer.  The  lumen  of 
the  artery  is  entirely  filled  with  a  new  formation,  which  has  become 
canalized  by  new  vessels  at  ddf;  c,  blood  pigment;  e,  hyalme 
material,  part  of  the  new  formation  encroaching  on  the  media  at  e, 
and  seen  elsewhere.  (Drawn  by  Dr.  W.  L.  Wardwcll,  from  a  speci- 
men borrowed  from  Prof.  W.  H.  Welch.     Magnified  00  diameters.) 


ARTERITIS.  175 

soon  after  the  operation,  probably  within  a  few  hours.     The  intima  was 
not  broken,  but  simply  bruised  within  the  grasp  of  the  ligature.     Active 
proliferation  of  the  cells  of  the  intima  had  resulted  from  this  irritation. 
Not  only  is  the  intima  seen  to  bulge  into  the  lumen  of  the  vessel,  but  the 
mass  of  embryonic  tissue  en- 
croaches outward  upon  the 
media,  which  is   thinner  at 
this    point  than   elsewhere. 
At  one  point  the  media  has 
entirely  disappeared,  leaving 
the  intima  and   externa  in 

actual  contact.     The  adven-       *^ -- ?-  "^~ '~      :^r 

titia  has  not  undergone  much         ^  ^  ,  c 

change.      A    few  inflamma-         """-':--       ^  ^^ 

tory   corpuscles    are    found  ;v^^       ■        ■'    '""^    fl'-A.^l:Z'~  "-^ 

among  the  connective-tissue        d  ..^§0^'^.-'''^"'''>^^^^''..;-o 

bundles.     If,  after  an  inju-  ^  'dj'"        '^  -         - 

ry  which  induces  arteritis,  ■     ' 

the    vessel    be    not    occluded  Fi<>-  249 -Traumatic  endarteritis.     Section  from  the  common 

carotid  ot  a  horse,  tied  Trith  a  broad  nerve-liirature,  show- 

thrOUghout  the  extent  of  the  i^S  at  bb  the  proliferation  of  the  intima.     The  inflamma- 

,      .                 ,      ,        .     .  tory  new  formation  is  projected  into  the  lumen  of  the  ves- 

lesion,  and   the   injury  or  re-  sel,  and  has  caused  partial  atrophy  of  the  media,  c;  ab, 

„.,n-;„™    A„f\    »„»„„j-';    „     i^„    „„  the  intima;   e b,  portion  of  the  intima  in  the  grasp  of  the 

suiting    inliammation     De    so  hgature;  d,  the  adventltia,  slisrhtly  changed,  with  small- 

sovprom-irl  intonco  tlnf  vQi-iirl  ^1'  infiltration.     (Drawn  by  Dr.  W.   L.  WardweU,  from 

Seveie  ana  intense  tnat  lapia  (,^g  author's  specimen.    Magnified  about  40  diameters.) 

occlusion  of  the  capillaries 

in  the  arterial  wall  takes  place,  suppuration  and  ulceration  of  the  wall 
occur,  with  haemorrhage.  Or  septic  matter  may  pass  into  the  vessel 
from  the  surrounding,  inflamed,  tissue,  and  lead  to  infarction  and 
pyaemia.  The  same  condition  may  result  from  an  extension  of  in- 
flammation from  the  surrounding  tissues  into  the  arterial  wall,  as  in 
phagedeena. 

Treatment. — No  unvarying  plan  of  treatment  can  be  laid  out  for 
traumatic  arteritis.  The  circumstances  of  each  case  must  be  separately 
considered.  To  prevent  gangrene,  and  to  guard  against  haemorrhage, 
are  the  indications  most  to  be  regarded.  Rest,  position,  quiet,  and  care- 
ful nutrition,  are  the  most  imjjortant  points  of  treatment. 

Traumatic  arteritis  resulting  from  causes  ■witMn  the  vessels  usually 
begins  as  an  endarteritis.  It  may  never  involve  any  other  tunic  than  the 
intima.  Many  cases  of  acute  traumatic  endarteritis  are  described  as 
idiopathic  inflammations.  They  are  none  the  less  due  to  violence — to 
the  impinging  force  of  the  blood-current ;  for  this  lesion  occurs  at  those 
points  in  the  arterial  system  where  the  pressure  is  greatest.  Endarteritis 
and  the  fatty  degeneration  resulting  from  it  (Figs.  250,  251)  are  most 
frequently  seen  in  the  sinus  magnus  of  the  aorta,  in  the  transverse  seg- 
ment of  the  arch  of  the  aorta,  at  the  aortic  bifurcation  into  the  two 
common  iliacs,  and  in  the  arch  of  the  innominate.  The  arteries  of 
athletes,  which  are  subjected  to  prolonged  distention,  resulting  from 
violent  muscular  exercise,  are  prone  to  suffer  from  this  disease. 


176 


A  TEXT-BOOK  ON  SURGERY. 


Vegetations  from  the  laeart  may  produce  endarteritis  when  they  are 
extensive  enough  to  pass  through  the  aortic  valves.  Fragments  from 
vi^hatever  source,  carried  along  the  vessels,  produce  arteritis  at  the  point 
of  lodgment. 


Fig.  250. — Arteritis  with  fatty  degeueration  of  the 
intima  of  the  aorta.  The  nuclei  of  the  noraial 
cells  are  represented  by  the  larger  bodies,  cue 
of  which  is  seen  at  m  ;  the  smaller  bodies,  as  at 
^,  are  fatty  granules.  Matrnified  400  diameters. 
(From  CornU  and  Eanvier.) 


Fig.  251.— a  form  of  fatty  deirenoration  after  arteritis. 
Fatty  detreneration  of  the  internal  coat  of  the 
aorta.  Minute  yellowisb-white  patches  scattered 
over  the  lining  membrane  of  the  vessel.  A  very 
thin  layer  peeled  off  and  magnified  200  diameters, 
showing  fat  molecules  and  the  distribution  of  fat 
in  the  iritima.     (From  Green.) 


If  we  examine  the  Intima  of  an  artery  which  has  been  the  seat  of 
recent  endarteritis,  it  will  be  seen  to  be  swollen,  and  thicker  and  softer 
than  in  healthy  vessels.  The  swelling  is  not  usually  general  and  con- 
tinuous, biit  occurs  in  patches  or  hillocks  of  quite  regular  contour,  which 
project  into  the  lumen  of  the  vessel.  The  intima  is  usually  injected,  and 
reddish  in  color,  though,  according  to  Cornil  and  Eanvier,  when  the  in- 
flammation has  been  of  a  very  severe  type,  the  swollen  intima  is  paler 
than  normal.  If  the  inflammation  be  of  recent  origin,  these  patches  will 
present  an  unbroken  surface  ;  but  if  softening  has  occurred,  the  centers 
of  the  elevations  break  down,  resulting  in  erosions  or  ulcers,  as  they  have 
been  styled  by  some  pathologists.  Green  says  that  they  are  due  to  soft- 
ening of  the  intercellular  substance,  and  that  the  cells  and  granular 
matter,  becoming  loose  from  this  softening,  are  washed  out  by  the  blood- 
current.  These  erosions  resemble  considerably  the  superficial  erosions 
found  often  in  the  mucous  membrane  of  the  stomach.  At  times  they  are 
covered  over  with  a  layer  of  fibrin,  which,  upon  close  inspection,  is  found 
to  be  composed  of  one  or  more  laminee  of  fibrillated  fibrin,  with  corpus- 
cular elements  entangled  in  or  resting  between  them. 

Beneath  the  jDrojecting  intima  is  found  a  mass  of  inflammation-tissue, 
consisting  of  embryonic  and  large  anastomosing  cells  resembling  the 
normal  connective-tissue  cells  of  the  most  external  structure  of  the  intima. 
Hyperplasia  of  the  normal  cell-elements  is  more  marked  as  we  approach 
the  inner  layers  of  cells  of  which  the  intima  is  composed,  the  prolifera- 
tion growing  gradually  less  extensive  as  the  elastic  lamina  is  neared. 
This  condition  is  a  feature  of  acute  endarteritis,  and  differs  both  from 
the  inflammation  of  the  atheromatous  process  and  from  syphilitic  endar- 
teritis. 

This  mass  of  new-formed  embryonic  tissue  is,  in  all  probability,  the 
immediate  result  of  proliferation  of  the  normal  cell-elements  of  the  intima. 


ARTERITIS. 


177 


^ 


Emigrant  corpiiscles  could  onlj^  reach  tMs  location  by  ti-aversing  tlie 
media,  for  as  yet  the  capillaries  have  not  been  projected  into  the  inner 
tunic.  ]S"or  is  it  probable  that  leucocytes,  from  the  blood-current  within 
the  artery  involved,  migrate  through  the  endothelia  into  the  proliferat- 
ing mass. 

The  adventitia  does  not  long  remain  undisturbed  by  the  pathological 
changes  which  have  occurred  in  the  intima.  It  takes  on  an  inflammatory 
process  in  a  varying  degree,  and  this  tunic  is  found  thickened  fi-om  the 
proliferation  of  its  connective-tissue  cells.  If  the  process  be  obstinate 
and  persistent,  a  true  arteritis  is  develojied,  and  aU  the  pathological  con- 
ditions which  have  been  described  on  a  previous  page  may  be  present. 

The  media  is  not  greatly  altered  in  the  early  stages  of  endarteritis  or 
periarteritis,  though  in  calcification  it  is  apt  to  be  first  attacked,  as  it  is 
likewise  in  fatty  infiltration  and  degeneration. 

Acute  endarteritis  may  tenninate  in  recovery,  leaving  no  pemianent 
trace  of  its  having  existed,  or  it  may  pass  into  a  chronic  inflammation, 
which  usually  ends  in  fatty  de- 
generation. 

This  degeneration  begins  in 
the  endarteritis  proper,  and  trav- 
els toward  the  media.  The  ap- 
pearances of  an  artery  which  has 
undergone  this  change  are  well 
shown  in  Fig.  252. 

Fatty  degeneration,  in  its  mi- 
croscoi^ic  appearances,  resembles 
very  much  the  atheroma  which  is, 
at  times,  found  in  the  intima.  It 
can,  however,  by  gentle  and  care- 
ful scrajDing,  be  removed,  reveal- 
ing the  more  or  less  normal  tissues 
underneath,  while  in  advanced 
atheroma,  which  involves  the 
deeper  structures  first,  no  trace 
of  the  normal  tissues  can  be  dis- 
covered. 

Chronic  arteritis  may  follow  an  acute  endarteritis,  as  has  been  indi- 
cated above,  although  the  chronic  arterial  lesions,  as  a  rule,  begin  with 
periarteritis  or  mesarteritis. 

II.  ISTox-TsAUMATio  OE  IDIOPATHIC  ARTERITIS. — The  inflammatory 
process  in  idiopathic  arteritis  differs  only  in  degree  from  that  heretofore 
described  as  occurring  in  traumatic  arteritis.  When  not  due  to  syphilis, 
gout,  rheumatism,  nephritis,  or  some  dyscrasia,  it  is  usually  a  part  of  an 
inflammation  of  the  tissues  immediately  sirrroiinding  an  artery.  The 
process  commences  in  the  adventitia,  and  is  analogous  to  that  of  trau- 
matic arteritis. 

Atheroma  and  Calcification. — One  of  the  frequent  and  most  serious 
terminations  of  chronic  arteritis,  no  matter  what  may  have  produced  the 

12 


■    J 


■■^M. 


y!^/l/p'(^-%ffi 


'I 

Fig.  252. — Arteritis  with  fattv  degeneration.  Fatty  de- 
generation of  tlie  interaal  coat  of  the  arteries  from 
a  thin  layer  stripped  from  this  membrane,  a,  Fat 
granules  in  irregular  patehes  over  the  surface.  The 
granules  have  resulted  from  fatty  degeneration  of 
the  cells  of  the  intima.  S,  Fibrillated  tissue.  Mag- 
nified 200  diameters.     (Comil  and  Eanvier.) 


178 


A  TEXT-BOOK   ON   SURGERY. 


arterial  lesion,  is  the  condition  Isnown  as  atheromatous  degeneration  (Fig, 
253).  It  is  essentially  a  disease  of  malnutrition.  It  is  a  senile  change, 
not  of  necessity  co-existent  with  another  disease.  It  is,  as  will  be  proved 
hereafter,  prone  to  attack  the  arteries,  especially  those  of  the  brain,  in 


Fig.  253. — Atheroma  following  arteritis.  Section  of  aorta  undergoing  the  atheromatous  change,  showing  the 
cellular  infiltration  of  the  deeper  layers  of  the  inner  coat,  and  consequent  bulging  inward  of  the  intmia. 
The  new  tissue  has  undergone  more  or  less  fatty  degeneration.  There  is  some  cellular  infiltration  of  the 
middle  coat,  i,  the  internal ;  m,  the  middle  ;  e,  the  external  tunic.  Magnified  50  diameters  and  reduced 
one  half.     (Green.) 

syphilis,  and  the  larger  arteries  in  other  affections.  The  fatty  degenera- 
tion of  endarteritis  is  a  primary  lesion,  that  of  chronic  arteritis  is  sec- 
ondary. The  one  is  local,  the  other  general.  Recovery  from  the  one  is 
possible,  and  the  danger  of  death  is  slight.  Shreds  of  fatty  material  may 
be  carried  by  the  blood  and  lodged  in  the  cerebral  or  other  remote  ves- 
sels, doing  great  injury ;  but  this  accident  is  rare.  The  possibilities  of 
chronic  arteritis  with  atheroma  are  always  grave.  Above  the  dangers  of 
thrombosis  and  embolism,  and  of  calcification,  are  those  of  aneurism  and 
of  haemorrhage.  The  early  recognition  of  this  condition,  though  exceed- 
ingly difficult,  is  no  less  important.  Atheroma  commences  in  the  deeper 
tissues  of  the  arterial  wall,  and,  advancing  in  the  line  of  blood-supply, 
taps  the  sources  of  nutrition  of  the  deeper  tunics,  causing  their  loss  of 
function,  death,  and  disappearance.     It  is  a  true  necrobiosis. 

The  fatty  degeneration  of  atheroma  not  only  involves  the  innermost 
layer  of  the  intima  (as  does  that  form  of  degeneration  which  follows 
endarteritis),  but  the  muscular-fiber  cells  undergo  complete  metamor- 
phosis, while  the  elastic  lamina  is  the  seat  of  extensive  infiltration.  In 
severe  cases  the  work  of  destruction  is  complete,  the  normal  tissues  dis- 
appearing, and  leaving  nothing  but  a  granular  debris. 

Atheroma  does  not  usiaally  destroy  an  extensive  area  of  the  intima. 
The  patches  may  be  numerous,  but  not  large.  The  molecular  disintegra- 
tion is  confined  to  certain  well-defined  spots,  in  the  center  of  which  is 
found  the  softened,  broken-down  "pulp"  which  has  given  rise  to  the 
term  "atheroma."  Examined  under  the  microscope,  the  contents  of 
these  pulp-cavities  will  be  found  to  consist  of  fat  granules,  granular 
corpuscles,  and  cholesterin  crystals,  exactly  analogous  to  those  some- 
times found  in  abscesses  of  long  duration.     Shreds  of  fibrous  tissue  may 


ARTERITIS.  179 

be  present.  It  can  be  readily  conceived  how  the  rupture  of  one  or  more 
of  tliese  j)ulp-cavities,  togetlier  with  the  weakened  state  of  the  middle 
and  outer  coats,  would  lead  to  the  formation  of  aneurism.  This  danger 
is  not  so  imminent  when  the  inflammatory  process  has  advanced  slowly, 
for  the  reason  that  secondary  calcification  (a  conservative  process)  is 
more  apt  to  take  place.  The  same  may  be  said  of  primary  calcifica- 
tion where  the  lime  salts  are  dei^osited  in  the  "coagulation  necrosis"  of 
the  media. 

The  atheromatous  and  calcareous  degenerations  may  exist  in  the  same 
location  and  at  the  same  time.  While  the  cell-structure  of  the  intima  is 
being  transformed  into  granular  matter,  the  fibrillated  basement  sub- 
stance nearest  the  media  is  the  seat  of  calcai'eous  deposit,  at  first  granular, 
the  granules  adhering  to  form  clusters  or  flakes.  At  the  same  time,  the 
nuclei  of  the  muscular-fiber  cells  are  filled  in  and  around  with  calcareous 
matter.  The  entire  muscular  coat  may  be  converted  into  a  calcified 
cylinder,  or,  as  is  most  usual,  the  process  may  be  confined  to  isolated 
patches.  In  either  case,  the  entire  thickness  of  the  wall  may  eventually 
undergo  the  same  morbid  changes. 

When  the  layer  of  cells  between  the  calcareous  deposits  and  the  blood- 
current  has  been  broken  down  by  the  atheromatous  process,  it  may  dis- 
appear in  the  blood  and  leave  the  flakes  of  calcareous  matter  ex]3osed  to 
view  from  witliin.  These  in  turn  may  be  carried  away,  or  they  may  be 
undermined  by  the  blood-current  and  lead  to  aneurismal  pouches  by 
dissection.  With  atheroma,  calcareous  degeneration  may  invade  the 
entire  arterial  system,  the  arteries  of  the  extremities  becoming  brittle  and 
unyielding.  The  smaller  arteries  ai-e  most  apt  to  be  involved,  especially 
those  of  the  brain. 

In  many  cases  of  atheromatous  and  calcareous  degeneration  in  the 
aged,  enoi'mous  dilatations  occur.  The  dilatation  is  not  uniform,  as  a 
rule,  but  the  walls  of  the  dilated  artery  (usually  the  aorta  and  the  arte- 
ries of  the  second  class)  are  pouched  in  many  jalaces.  The  calcareous 
matter,  will  be  found  to  be  thickest  in  those  portions  of  the  wall  which 
are  less  dilated,  while  the  dilated  pouches  have  undergone  a  more  com- 
plete fatty  degeneration. 

This  condition  is  common-      ^  _  *  ^^^ 

ly  known  as  arteritis  de-  ;~ 

formans. 

The  middle  coat  may 
be  in  places  entirely  de-  '  ^ 

stroyed,  when  the  changed  ^ 

intima  will  be  joined  with 
the  adventitia  by  a  con- 
nective-tissue  new-forma-         d  ^-^^  ^_— _  _   ^.^j; 
tion,  which  (see  Fig.  247)  " 

,     .                    n               .         -] .  Fig.   254. — Showinar  calcareous   desieneration  of  the  media,     a, 

contains  vessels  passing  CLl-  intima;   cc,  media;   d,  adventitia;   bb,  calcareous   patches, 

rppfl-tr  fn  f-TiP  intlmn        T,n<as!  Llnar  artery.     Magnified  about  60  diameters.    ( From  a  speci- 

lecuy  lO  me  lUlima.      UOSS  ^^^  prepared  by  Dr.  W.  L.  Wardwell.) 

of  the  elastic  tunic  is  one 

of  the  immediate  causes  of  spontaneous  aneurism  (Cornil  and  Ranvier). 


180 


A  TEXT-BOOK   ON  SURGERY. 


fhf)] 


ill 


S% 


\  I 


A\'& 


i' 


This  condition  of  atrophy  of  the  elastic  lamina  is  weU  shown  in  Fig. 
254,  which  was  drawn  fi'om  one  of  my  specimens. 

Calcification  of  arteries  has  been  especially  studied  by  Dr.  W.  L. 
Wardwell,  of  New  York  city,  in  Conheim's  Laboratory.     His  experience 

includes  examinations  made 
from  twenty-five  cases  at  the 
request  of  Conheim,  who  as- 
sents to  his  conclusions.  Dr. 
WardweU  says  all  authorities 
I'ecognize  a  morbid  change  in 
the  arteries  known  as  calcifi- 
cation, and  the  majority  look 
upon  it  as  a  change  second- 
ary to  atheroma  or  endarte- 
ritis. Few  of  these  recognize 
a  primary  calcification  not 
dependent  upon  a  preceding 
inflammation.  This  condi- 
tion is,  however,  the  chief 
change  in  the  senile  calcifi- 
cation of  arteries.  The  mi- 
croscopic appearances  of  pri- 
mary calcification  are  well 
shown  in  Fig.  255. 

Conheim  states  that  in 
senile  arterial  calcification 
sometimes  the  media,  sometimes  the  interna  (its  outermost  layer),  is 
affected,  and  that  in  them  the  lime  salts  are  deposited.  Moreover,  that 
this  deposit  of  lime  takes  place  here  because  these  tunics  have  been  sub- 
jected to  the  greatest  strain. 

Weigert*  describes  a  "  hitherto  undescribed "  process  known  as  co- 
agulation  necrosis.  Beginning  with  the  theory  of  Schmidt  concern- 
ing the  coagulation  of  the  blood,  in  v/hich  the  white  corpuscles  play  the 
leading  part,  he  argues  that  all  tissues  have  the  power  of  SjDontaneously 
coagulating,  it  being  necessary  for  such  an  occurrence  that  the  cells 
should  die,  give  up  their  ferment  and  fibrin o-plastic  material,  and  then 
become  saturated  with  a  fibrinogen-holding  lymph.  This  morbid  process 
he  holds  may  occur  in  tissues  the  most  diverse  in  character,  as  in  cheesy 
glands,  infarcts  of  the  spleen  or  kidneys,  tumors,  the  inflammatory  ma- 
terial around  parasites,  tubercle,  etc.  Macroscopically,  these  coagulated 
spots  have  a  peculiar,  stifl'  appearance,  and,  microscopically,  they  are 
recognized  by  the  fact  that  the  cell  nuclei  have  disappeared,  and  can 
not  be  made  to  aj)pear  by  reagents  or  by  the  material  used  for  staining 
in  microscopical  examination. 

Following  the  line  of  research  indicated  by  Conheim  and  Weigert,  it 
may  be  concluded  :  1.  That  in  the  arteries  of  middle-aged  or  old  persons 


Fig  255 — Arteritis  with  pi iinaiy  calcjflcatnn  Section  fiom 
liuman  radial  artery,  showing  at  b  primary  calcification  of 
the  media,  o.  a,  the  intima  comparatively  unchanged. 
(Drawn  from  specimens  prepared  hy  Br.  W.  L.  Ward- 
well,  at  Conheim's  Laboratory.  Magnified  about  350 
diameters. ) 


*  Virchow's  "Archiv,"  Bd.  Isxix,  S.  87. 


ARTERITIS. 


181 


Fig.  256. — Arteritis  with  congulation-neerosis.  Section  from 
human  aiteiy  ti'eated  with  acetic  acid,  showing  at  d  spots 
of  coagulation-necrosis  which  contained  calcareous  salts 
before  being  treated  with  the  acid  ;  a,  intiraa ;  b,  media ; 
adventitia.  (Drawn  ii-otn  specimen  prepared  by  Dr. 
Alagnilied  about  40  diameters.) 


c,  auveui'itia.       ^j 
W.  L.  Wardwell. 


there  are  often  found  spots  of  diseased  tissue  which,  present  all  the  ap- 
pearances of  having  undergone  a  "■coagulation  necrosis.'''' 

2.  That  in  these  spots  there  is  a  tendency  to  the  deposition  of  lime 
salts. 

3.  That  in  primary  calcification  the  media  is  always  tirst  affected,  the 
intima  and  adventitia  only  secondarily  and  by  contiguity. 

4.  That  this  change  is  in- 
dependent of  a  preceding  in-  '-  ,   -  -7'^^ 
flammation. 

5.  That,  on  the  contrary,  a 

these  calcified  spots  act  as         _  b 

foreign  bodies,  setting  up  a  • 

secondary    inflammation    in       /g        .  __ 

their   vicinity,    and    leading       fg-     —      —^  ~     _^^~^    _r-~~         "T        c 

sometimes  to  thickening  of 

the  intima. 

6.  That  one  of  the  changes 
in  atheroma  of  the  arteries 
is  coagulation-necrosis,  that 
lime  salts  are  often  deposited 
in  such  necrotic  sioots,  that 
the  position  of  such  spots  is  in  the  intima  instead  of  the  media,  viz.,  in 
the  newly  formed  inflammatory  tissue. 

7.  That  primary  calcification  attacks  the  small  arteries  rather  than 
the  larger,  and  especially  those  portions  of  the  arteries  which  are  subject- 
ed to  the  greatest  strain.* 

-  ^  -:=^r=sB?r-:ffe,s^    ^  These  conditions  are 

shown  in   Figs.  256  and 
257. 

Syp'hilitic  Arteritis. 
— Arteritis  is  a  part  of 
the  pathology  of  syphilis. 
The  first  danger  to  life  in 
this  disease  comes  from 
the  changes  in  the  ca- 
pacity of  the  arteries. 
No  part  of  the  arterial 
system  is  exempt,  though 
the  most  serious  lesions 
are  found  in  the  vessels 
of  the  brain,  and  next  in 
the  aorta.  They  become 
grave  in  the  larger  trunks 
on  account  of  the  athero- 
ma resulting  from  the 
syphilitic  poison  (indue- 


'03 


,^^--~—   ^^7^:     C 


Fig.  25'i. — Posterior  tibial  artery.  Section  showing  coagulation-ne- 
crosis. A,  intima ;  e,  media ;  c,  adventitia ;  n,  spot  of  coagu- 
lation-necrosis. Magnified  360  diameters.  (From  a  specimen 
prepai-ed  by  Dr.  W.  )X.  Wardwell. ) 


'  For  these  conclusions  the  author  is  indebted  to  Dr.  W.  L.  "VVardwelL 


182 


A   TEXT-BOOK   ON   SURGERY. 


ing  aneurism),  and  in  the  smaller  arteries  (especially  those  of  the  brain) 
from  occlusion  or  atheroma. 

Even  in  the  initial  lesion  of  syphilis  (the  chancre),  according  to 
Biesiadecki,  the  capillaries  of  the  papillee  have  in  their  thickened  walls 
many  nuclei,  some  of  which  are  seen  to  pi'oject  into  the  lumen  of  the 
vessel. 

The  arteries  of  the  base  of  the  brain,  especially  the  basilar  and  those 
at  the  commencement  of  the  fissure  of  Sylvius,  are  often  seriously  in- 
volved. I  have  seen  two  cases  in  private  practice  in  which  death  resulted 
from  anaemia  of  the  medulla,  due  to  a  more  or  less  complete  thrombosis 
of  the  basilar  artery.  A  patient  of  Dr.  Weber's,  to  whom  I  was  called, 
died  in  my  presence.  A  few  days  previous  to  his  death  he  had  com- 
plained of  dizziness,  and  of  a  sensation  as  of  insects  crawling  over  the 
integument  of  the  extremities.  Death  was  quite  sudden,  and  was  due 
to  respiratory  failure.  He  became  quickly  unconscious,  the  respiratory 
movements  were  irregular,  and  co-ordination  of  movement  between  the 
expiratory  and  inspiratory  muscles  was  seemingly  lost.  The  mode  of 
death  was  different  from  anything  I  had  ever  witnessed.  At  the  autopsy, 
the  basilar,  just  where  it  divided  into  the  two  posterior  cerebrals,  was 
found  almost  completely  occluded  by  a  thrombus.  There  was  no  other 
lesion  which  could  have  accounted  for  death.  Syphilis  had  existed  for 
several  years. 

In  the  second  case  syphilis  had  existed  for  nineteen  years,  with  right 
hemiplegia  for  the  last  sixteen  years  of  life.     This  patient  was  under  my 

care  for  nearly  five  years. 
She  would  never  consent 
to  take  the  iodides  or  any 
medicine.  Her  mind  was 
clear  up  to  the  time  I 
last  saw  her  before  death, 
which  occurred  suddenly 
one  night.  I  did  not  see 
her  until  life  was  extinct, 
but,  from  the  description 
of  the  mode  of  death  given 
me  by  Dr.  F.  J.  Ives,  who 
was  present,  I  was  led  to 
express  the  belief  that  a 
similar  condition  existed  as 
in  the  case  first  referred  to. 
On  examination,  I  found  a 
thrombosis  of  the  basilar 
artery  in  exactly  the  same 
location.  Fig.  258  repre- 
sents a  section  of  the  artery 
near»the  thrombus.  The  lumen  of  the  vessel  is  seen  to  be  about  two  thirds 
occluded.  The  adventitia  is  slightly  thickened,  and  the  cell-elements  in 
it  are  distinctly  fusiform,  and  regularly  parallel  with  each  other  and  with 


^^^\ 


Fig.  258. — Sypliilitio  arteritis.  Section  of  basilar ;  e,  lumen  of 
vessel  about  two  tliirds  filled  with  new  formation  at  a  b  ; 
c,  media ;  d,  muscular  layer  and  adventitia.  From  a  patient 
dead  from  syphilis.  (Specimen  of  the  author's,  drawn  by 
Dr.  Wardwcil.    Magnified  about  40  diameters.) 


ARTERITIS.  183 

the  contour  of  the  adventitia.  The  wavy  elastic  layer  is  easily  recognized, 
and  in  that  portion  of  the  artery  in  which  the  syphilitic  inflammatory 
material  is  deposited  the  waves  of  the  media  are  more  numerous  and 
shorter  than  in  other  portions  of  the  vessel.  In  the  center  of  the  mass, 
occupying  a  portion  of  the  caliber  of  the  artery,  is  found  a  hyaline-look- 
ing sj)ot  which  took  the  carmine  stain  more  readily  than  the  general  mass 
of  the  thrombus.  It  contains  embryonic  cells  in  about  the  same  quantity 
as  the  surrounding  tissue.  The  adventitia  is  not  regularly  thickened, 
being  three  or  four  times  as  deep  in  some  portions  as  in  others,  and  pre- 
senting in  the  section  a  nodulated  appearance.  Viewed  with  a  magnify- 
ing power  of  about  five  hundred  diameters,  that  portion  of  the  arterial 
wall  external  to  the  wavy  line  (the  elastic  layer),  seen  in  Fig.  258,  presents 
the  following  appearance : 

In  the  most  external  limit  of  the  section  of  the  adventitia  there  are 
found  clusters  of  inflammatory  corpuscles,  true  embryonic  cells,  round, 
and  larger  than  the  cells  found  in  any  other  portion  of  the  specimen 
external  to  the  elastic  lamina.  These  cells  are  somewhat  smaller  in  size 
than  those  found  in  the  new-formed  tissue  of  the  intima,  though  they 
differ  in  shape,  since  those  in  the  intima  appear  both  round  and  fusiform, 
while  the  cells  in  the  outer  edge  of  the  externa  appear  almost  invariably 
round.  It  may  be  possible  that  they  are  fusiform  cells  cut  transversely 
in  the  section ;  though  after  careful  examination  I  am  led  to  conclude  that 
they  are  round.  At  various  points  these  cells  do  not  exist,  the  external 
layer  being  that  of  fiisiform  cells  arranged  with  great  regularity  parallel 
to  the  contour  of  the  wall  of  the  artery.  Where  the  wall  of  the  vessel 
external  to  the  elastic  lamina  is  thickest,  these  spindle  cells  are  more 
numerous,  and  have  a  greater  transverse  diameter  than  at  the  narrower 
portions,  where  they  seem  to  have  elongated  and  become  thinner — seem- 
ingly a  true  process  of  fibrillation  and  contraction  of  embryonic  (inflam- 
matory) cells. 

Continuing  the  examination  farther  inward,  as  the  white,  wavy, 
elastic  zone  is  crossed,  Just  within  and  almost  in  exact  apposition 
with  this  is  a  somewhat  irregular  and  thin  layer  of  cells,  fusiform 
in  section,  varying  in  depth  from  a  single  row  to  two  or  three  rows, 
and  in  some  points  entirely  absent.  These  are  doubtless  a  remnant 
of  the  original  endothelia  of  the  intima :  just  internal  to  these,  and  in 
fact  continuous  A\'ith  them,  is  the  great  mass  of  new-formed,  inflamma- 
tory tissue  which  juts  into  the  lumen  of  the  vessel.  This  mass  is  com- 
posed of  large,  mostly  fusiform,  cells,  distinctly  nucleated  and  occupy- 
ing about  as  much  space  as  the  intercellular  substance  in  which  they  are 
imbedded. 

Syphilitic  arteritis  has  been  made  the  subject  of  special  study  by 
Cornil,  Heubner,  Greenfield,  Barlow,  Buzzard,  Davidson,  Simes,  White, 
and  others. 

Greenfield,  in  the  "Transactions  of  the  Loudon  Pathological  Society 
for  1877,"  gives  an  analysis  of  22  cases  of  visceral  syphilis. 

Of  the  22  patients,  13  were  females,  9  males.  Their  ages  varied  from 
23  to  50  years.     Of  the  females,  4  were  between  the  ages  of  28  and  25,  i 


184  A  TEXT-BOOK   ON   SURGERY. 

was  35,  1  was  38,  the  remainder  between  40  and  50.  Of  the  males,  4  were 
between  30  and  40,  the  rest  between  40  and  50. 

These  patients  did  not  all  die  from  syphilis,  some  perishing  from  other 
and  concomitant  diseases.  Of  those  who  died  from  the  effects  of  syphilis, 
the  greater  number  were  comparatively  young.  Of  the  four  females 
under  twenty-five  years  of  age,  two  died  from  the  effects  of  thrombosis 
of  the  cerebral  arteries,  one  from  syphilitic  disease  of  the  larynx,  and 
one  from  accident.  Of  the  six  males  under  forty,  one  died  from  syphi- 
litic disease  of  the  cerebral  arteries,  one  from  gummata  of  the  brain  and 
dura  mater,  one  from  pneumonia  due  to  syphilitic  disease  of  the  larynx 
and  trachea,  one  from  renal  disease  consequent  upon  stricture,  and 
another  by  accident. 

In  the  total  of  twenty-two  cases,  the  condition  of  the  vascular  system 
was  noted  in  all  but  six.  In  one  case  there  was  no  lesion  of  the  arteries. 
In  the  remaining  fifteen  cases  the  arteries  were  more  or  less  seriously 
involved.  In  other  words,  out  of  sixteen  cases  in  which  the  condition  of 
the  arteries  was  noted,  in  fifteen  these  vessels  were  diseased. 

The  author  says  that  the  condition  of  the  aorta  and  large  vessels,  as 
regards  atheroma,  is  of  importance  in  connection  with  the  dependence  of 
aneurism  upon  syphilis,  and  that,  as  regards  the  smaller  vessels,  the 
nature  of  the  disease  of  the  cerebral  arteries  is  of  the  greatest  interest. 
In  three  females,  aged  twenty-three,  twenty-five,  and  twenty-five,  thei-e 
was  marked  atheroma  of  the  aorta.  In  one,  the  atheroma  was  general 
in  the  aorta  and  its  larger  branches,  the  condition  being  that  of  diffused, 
irregular  swelling,  with  but  little  fatty  degeneration.  In  one  female, 
aged  twenty-five,  in  the  first  part  of  the  arch  of  the  aorta  were  several 
patches,  rounded,  prominent  in  the  center,  and  thicker  than  usual.  On 
section  these  appeared  homogeneous,  and  presented  scarcely  any  fatty 
degeneration.  Throughout  the  rest  of  the  aorta  there  was  general  athe- 
roma, with  no  peculiar  characters.  In  another  female,  aged  thirty-five, 
there  were  large  patches  of  endarteritis  deformans  in  the  abdominal  aorta. 

In  several  other  cases  there  was  marked  atheroma,  and  in  most  cases 
where  there  was  no  renal  disease  the  patches  wei^e  much  raised,  some- 
times almost  hemispherical,  at  other  times  with  sharply  defined  edges  of 
gelatinous  appearance  and  pearly  luster ;  and  on  section  there  was  but 
little  fatty  degeneration  or  calcification. 

Whether  in  these  cases  the  disease  would  have  gone  on  to  the  forma- 
tion of  aneurism,  can  not  of  course  be  decided ;  but  it  is  evident  that  a 
marked  tendency  to  the  occurrence  of  endarteritis  deformans  at  an  early 
age,  and  in  an  advanced  degree,  exists  in  visceral  syphilis. 

The  cerebral  arteries  were  very  markedly  affected  with  syphilitic  dis- 
ease in  five  cases,  and  in  a  sixth  v/ere  probably  diseased. 

As  to  the  pathological  changes  which  syx)hilitic  arteritis  causes,  they 
are  given  by  Dr.  Greenfield  in  two  cases  of  disease  of  the  cerebral  arteries. 

The  specimens  were  taken  from  the  middle  cerebral  and  basilar  arte- 
ries. They  are  tyj^ical,  and  probably  represent  two  different  stages  of  the 
process.  In  the  first  case  the  disease  is  seen  in  the  earlier  form,  in 
which  it  consists  almost  entirely  of  a.  cell-growth  which  has  as  yet  under- 


ARTERITIS. 


185 


gone  but  little  organization.  In  the  second  case  considerable  changes 
have  occurred,  and  a  large  part  of  the  new  growth  is  converted  into  more 
or  less  fully  developed  connective  tissue.  In  the  specimen  sketched  in 
Fig.  259,  the  artery  is  seen  to  be  somewhat  irregular  in  shape,  this  being 
due  to  obliquity  of  the  section.  The  lumen  («)  is  very  small,  but  is  clearly 
defined,  rounded,  and  free  from  thrombus. 

The  outer  coat  aj^pears  somewhat  thickened,  and  is  infiltrated  in  con- 
tinuity with  the  pia  mater  (/").  The  muscular  coat  {d)  is  distinctly  seen 
at  the  upper  and  lower  parts  of  the  section,  elsewhere  being  somewhat 
infiltrated,  and  not  clearly  separated  fi-om  the  adventitia.  The  fenestrated 
membrane  is  clearly  seen  at  5,  where  it  is  indicated  by  the  dark  lines  ;  it 
could  be  clearly  traced,  on  altering  the  focus,  aU  around  the  vessel,  lying 
as  usual  immediately  internal  to  the  muscular  layers,  and  separating 
them  from  the  inner  coat.  It  is  to  that  part  of  the  vessel  lying  between 
a  and  h  (Fig.  259)  that  attention  must  be  specially  directed,  the  thickened 
inner  coat  constituting  the  essential  feature  and  the  peciiliarly  character- 
istic element  of  the  morbid  change.  With  a  higher  power,  the  thicken- 
ing of  the  inner  coat  is  seen  to  consist  entirely  of  a  cell-growth  which 
closely  resembles  granulation-tissue.  In  the  deeper  parts,  nearest  the 
fenesti-ated  membrane,  the  cells  appear  to  be  flattened,  running  parallel 
with  the  elastic  layer,  growing,  however,  more  irregular  in  disi^osition 
toward  the  center.  Xo  distinct  transition-hue  can  be  discovered  between 
this  deeper  layer  and  the  central  part,  in  whicli,  however,  the  cells  appear 
to  be  larger,  often  branching  and  more  loosely  arranged,  with  more 
numerous  capillaries  running  among  them.  Many  of  the  cells  in  the 
intermediate  layer  appear  to  be  rounded  ;  but  it  is  not  improbable  that 


Fig.  259 — S\philiUc  artenti'-  Shows  sec- 
tion of  bm.iU  cerebral  artery  near  a  sum- 
ma,  ma<]:nified  30  diameters,  ff,  lumen 
of  vessel ;  6,  boundary  of  inner  middle 
coats ;  c,  thickened  inner  coat ;  d.  mid- 
dle coat ;  e,  external  coat ;  ./",  infiltrated 
pia  mater.    (After  Greenfleld.) 


;  t^-  'vji 


Fig.  260.— Syphilitic  arteritis.  Section  of  small  artery 
of  cerebellum,  mai^nified  30  diameters,  a,  lumen 
of  Tessel;  c,  thickened  inner  coat;  d,  muscular 
coat ;  e,  outer  coat.     (After  Greenfield.) 


they  are  fusiform  cells  cut  transversely.     In  many  parts  of  the  thickened 
intima  the  capillaries  are  numerous  and  of  large  size. 

Toward  the  lumen  of  the  vessel  the  cells  again  assume  a  flattened  or 


186  A   TEXT-BOOK   ON   SURGERY. 

fusiform  shape,  and  several  layers  of  these  cells  closely  packed  together 
form  the  innermost  part  of  the  new  growth,  the  most  internal,  super- 
ficial layer  (that  in  immediate  contact  with  the  blood-current)  forming 
a  continuous  layer,  which  corresjDonds  in  its  functions  to  normal  endo- 
thelium. 

The  other  specimen  (Fig.  260)  appears  to  have  undergone  different 
changes.  The  coats  of  the  vessel  are  enormously  thickened,  and  the 
lumen  of  the  vessel  correspondingly  diminished,  so  as  to  become  a  nar- 
row chink  (the  section  is  somewhat  obliquely  made).  The  thickening  of 
the  wall  is  found  to  present  great  variations,  at  points  of  the  vessel  not 
farther  apart  than  one  twelfth  of  an  inch,  other  sections  at  that  distance 
from  the  one  represented  in  the  cut  not  being  more  than  one  half  as 
thick,  the  external  diameter  of  the  vessel  remaining  almost  constant. 
The  adventitia  (e)  is  slightly  thicl^ened  and  infiltrated  by  a  cell-growth. 
The  muscular  coat  {d)  is  of  pretty  uniform  thickness,  except  at  some 
points  where  invaded  with  cell-infiltration  from  the  adventitia.  The 
inner  coat  is  enormously  thickened,  and  presents  the  appearance  of  two 
concentric  rings,  the  boundary  between  which  is  more  or  less  defined. 
Examined  with  a  higher  power  (Fig.  261),  the  lumen  of  the  vessel  is 


-fi^iff^'^^f^S  I 


-,'f  ''.>J^% 


A. 


L 


'?^'3t^ 


Pig.  261.— Syphilitic  arteritis.  Segment  of  tlie  preceding;  specimen,  masnifled  170  diaraetera.  a,  lumen  of 
vessel:  b,  lenestrated  membrane;  o,  c,  thickened  intima;  d^  muscular  coat;  ;>,  adventitia;  g,  new- 
formed  imperfect  elastic  lamina.     (After  Greenfield.) 

found  free  from  thrombus.  The  membrana  fenestrata  is  well  defined. 
The  muscular  layer  presents  very  much  its  normal  appearance  at  some 
points,  except  that  the  fiber-cells  are  somewhat  granular.  At  some  points 
it  is  encroached  upon  by  the  cell-growth  from  the  outer  coat,  between 
which  and  the  muscular  coat  there  is  no  distinct  line  of  demarkation. 
Tlie  outer  coat  is  somewhat  irregularly  thickened  by  cell-growth,  which 
is  especially  abundant  around  the  vasa  vasorum,  which  are  very  numer- 
ous and  much  more  developed  than  usual.  At  some  points  small  vessels 
traverse  the  muscular  and  elastic  coats,  going  into  the  deeper  portions  of 
the  thickened  intima. 

The  inner  coat  measures  twice  the  thickness  of  the  outer  and  middle 


ARTERITIS. 


187 


coats  together.  Starting  from  the  fenestrated  membrane,  in  its  neigh- 
borhood there  is  found  a  rather  abundant  cell-growth  traversed  by  capil- 
laries. Nearer  the  intima  is  found  a  fibrous  tissue,  formed  of  elongated, 
fusiform  cells  and  delicate,  interlacing  fibrils  of  connective  tissue,  the 
whole  constituting  an  imperfectly  developed  fibrous  tissue.  Internal  to 
this  are  seen  more  niimerous,  I'ounded  cells,  some  of  which  are  of  larger 
size.  Nearer  to  the  lumen  are  seen  elongated,  oval  nuclei,  smaller  and 
more  highly  refractile,  and  more  closely  packed  together  (Greenfield). 
It  will  be  seen,  by  reference  to  my  own  case  already  given,  that  in  the 
changes  which  occurred  in  the  intima  it  was  analogous  to  Dr.  Greenfield's 
first  case,  while  in  the  irregular,  nodulated  condition  of  the  muscular 
layer  it  was  analogous  to  his  second. 

According  to  Greenfield,  the  inflammatory  matter  in  and  around  the 
perivascular  canals  in  syphilis  is  entirely  different  from  that  in  tuber- 
cular infiltration  of  these  canals. 

In  vessels  examined  by  Barlow,  the  same  changes  are  reported  as 
those  given  above  (Figs.  262,  263).     The  adventitia  and  muscular  coats 


Fig.  262.— Syphilitic  arteritis.  Transverse  section  of 
a  .segment  of  the  middle  cerebral  artery  of  a 
syphilitic  patient.  «,  the  thickened  intima;  e, 
the  endothelium ;  f,  the  fenestrated  membrane ; 
m,  the  muscular  coat ;  a,  the  adventitia.  ( From 
Barlow's  Specimens,  Green's  "  Pathology.") 


J?iG.  263. — Syphilitic  arteritis.  Section  from  a 
small  artery  of  tlie  pia  mater  cut  trans- 
versely, showing  the  inner  coat  mucli  thick- 
ened, a  diminution  of  the  lumen  of  the 
vessel,  and  a  considerable  infiltration  of 
the  adventitia.  A  clot  is  seen  to  occupy 
a  great  part  of  the  lumen  of  the  vessel. 
(From  Barlow's  Specimens,  Green's  "Pa- 
thology.") 


were  more  or  less  affected,  "but  obviously  the  principal  changes  have 
taken  place  in  the  intima."  Davidson  and  Buzzard  are  led  to  the  same 
conclusions  with  the  foregoing,  as  is  Green  in  his  "Pathology  and  Mor- 
bid Anatomy." 

Rlieumatic  Arteritis. — Arteritis  may  occur  in  connection  with  acute 
rheumatism.  Bryant  states  that  this  is  a  rare  form  of  disease.  Rheu- 
matic endocarditis  is  not  so  rare,  and  it  is  jjossible  that  endarteritis  may 
exist  in  the  aorta  in  many  cases  of  endocarditis.  This  and  the  arteritis 
of  gout  and  nephritis  (Fig.  264)  belong  to  the  domain  of  medicine  rather 
than  to  that  of  surgery,  and  will  not  therefore  be  considered  in  this  work. 


188 


A  TEXT-BOOK   ON   SURGERY. 


The  treatment  of  arteritis  resolves  itself  simply  into  the  treatment  of 
the  disease  of  which  it  is  a  part.     It  would  be  useless  to  increase  the 

length  of  this  article  by  a  re- 

,-— —      capitulation    of    the    various 

methods  and  remedies  which 

/''^  have  been  employed.     If  the 

'^~T>-,~,— _^^       ,^r^  jTi-  pathogeny   and   pathology   of 

^  ^      ^  the   affection  are  understood, 

its  therapy  is  not  difficult. 
B^  -  ^  "  Arterial   Thrombosis   and 

J,  p-  ^  ^  Embolism.  —  Though    not    as 

"'"'-,       ~         -  ~^   '~  frequent  as  in  phlebitis,  throm- 

^  bosis  and  embolism  often  re- 

"^-^0^^^^  ^^'^  from   arteritis.     The   pa- 

thology of  thrombosis  has  been 
given  in  the  section  on  phlebi- 
tis. The  process  in  the  arteries 
is  closely  analogous  to  that  in 
the  veins. 

The  perfect  type  of  throm- 
bosis   from    acute,    traumatic 
arteritis,  is  found  after  the  application  of  an  occluding  ligature  around 
an  artery. 

By  reason  of  arrest  of  the  blood-current  and  disturbance  of  the  equi- 
librium normally  existing  between  the  blood  and  the  containing  vessels, 
coagulation  takes  place  on  the  cardiac  side  of  the  ligature,  extending 
back  as  a  rule  to  the  first  collateral  branch.  Immediately  following  the 
injury  to  the  vessel,  the  process  of  inflammation — true  arteritis — com- 
mences.    The  tension  of  the  ligature  to  such  a  degree  as  to  divide  the 


leph 

posterior  tibial  artery  of  patient  dead  from  Bright's  dis- 
ease, showing  at  a  great  thickening  of  the  intima,  the 
result  of  chronic  endarteritis.  The  elastic  lamina,  d, 
unchanged.  The  muscular  layer,  b,  slightly  thickened, 
c,  advcntitia  greatly  thickened  at  places  by  small-cell 
infiltration.     Drav^n  from  specimens  prepared  by  " 


W.  L.  Wardwell,  at  Conheim's  Labor.atory. 
fied  about  40  diameters.) 


Dr. 

(liagni- 


Fio.  265. — Longitudinal  section  of  the  artery  of  a  dog  fifty  days  after  the  ligature.     Clot  injected.    Magnified 
40  diameters.   '(After  O.  Weber.) 

inner  or  middle  coat,  or  both,  is  unnecessary.     I  have  tied  arteries  (carotid 
and  subclavian)  in  human  beings,  and  in  horses  and  dogs,  and  have  speci- 


ARTERITIS. 


189 


mens  wliich  demonstrate  successful  occlusion  of  the  vessel  without  divis- 
ion of  either  of  the  three  tunics.  Scarpa  advanced  this  idea  years  ago, 
but  surgeons  generally  have  decried  it. 

The  coagulation  thrombus  disappears  by  fatty  degeneration.  The 
permanent  occlusion  is  due  to  new-formed  tissue  springing  from  the 
normal  cells  of  the  intima  and  the  leucocytes.  O.  Weber  held  that  the 
clot  became  organized  into  a  true  tissue,  into  which  blood-vessels  were 
projected  from  the  vasa  vasorum  (Fig.  265).  But  Cornil  and  Ranvier 
long  since  disproved  this  assertion  of  Weber.  Bubnoff  held  that  the 
white  blood- corpuscles  emigrated  through  the  walls  of  the  ligatured  ves- 
sel, permeated  the  clot,  and  caused  its  organization  ;  but  Durante  (Cornil 
and  Ranvier )  has  demonstrated  that  the  leucocytes  only  traverse  the  walls 
of  the  vessel  when  this  has  been  tied  with  a  double  ligature,  causing  a 
death  of  the  included  vessel,  and  that  the  leucocytes  travel  through  this 
dead  tissue.  They  do  not  permeate  the  walls  of  an  otherwise  healthy 
artery  which  has  l)een  tied  mtli  a  single  ligature. 

Cell-proliferation  takes  ]3lace  rapidly  in  the  intima  ;  granulation-buds 
project  into  the  territory  occupied  by  the  clot  (Fig.  266) ;  blood-vessels 
derived  from  the  vasa  vasorum 
permeate  the  projecting  granu-  ~      't 

lation-tissue,  invade  the  clot,  ^^  "'^^ 

meet  with  live  vessels  fi-om  the  *^ 

opposite   side,   and  join  with  !^^  "3"   _^ 

these   in  a   continuous   circu-  ^^ 

lation  ;   the   embryonic   tissue       "  j 

organizes,  gradually  contracts  "  « 

(process  of  cicatrization),  and 

the  walls  of  the  vessel  are  per-  ,         -, 

manently  occluded  by  this  fibril-         l  N  r 

lation.      Afterward    the    new-  iM'  ^        * 

formed  vessels  disappear  to  a   "      ^^  - 

great  degi-ee,  being  obliterated  '**'  ""'"'©> 

by  the  process  of  contraction.  "^  ^  [{'Xf", 

Fig.  249,  from  a  section  of  -^  "^f-^" 

the  carotid  of  a  horse,  shows 

how  this   rapid  proliferation  of  ^^^    ase.-Traumatio  endarteritis.    Transverse  section  ot 

the   normal  cells  of   the  intima  U^e  femoral  artery  of  a  dog  eight  daysafter  tlie  appli- 

.       .  cation  of  a  ligature.     6,  the  elastic  lamina ;  p^  the  me- 

OCCUrS  when  the  mtmia  has  not  dia;    S,   granulatlon-bud  projecting  from  the  intima 

1               -1 .    .  -1     T          rr\u                        '  '^^^'^  the  lumen ;  ?;,  new-formed  vessel  running  through 

been    CtlVldea.        i  Here    was    in  the  inHammatmy  tissue.     At  a  the  elastic  layer  has 

this  case  simply  an  irritation  romiianWanvkr'.) '^"'"'^''^  ^" '^'''°'''''''   ^^™"' 

of  the  intima,  a  bruising,  the 

result  of  jamming  together  the  opposing  surfaces  of  the  intima  by  means 
of  a  broad  (not  cutting)  ligature. 

Thrombosis  from  acute  arteritis  is  rare.  Chronic  arteritis  is  not  in- 
frequently the  cause  of  occlusion.  Syphilitic  arteritis  is  apt  to  develop 
thrombosis  of  the  cerebral  arteries.  Arterial  thrombosis  (excluding  the 
vessels  to  the  brain  and  walls  of  the  heart)  is  not  as  dangerous  to  life  as 
venous  thrombosis. 


190  A  TEXT-BOOK   ON  SURGERY. 

The  process  is  usually  so  gradual  that  the  collateral  circulation  is 
established  before  occlusion  of  the  main  trunk  occurs.  This  may,  in- 
deed, escape  observation  until  the  enlarging  superficial  arteries  attract 
attention. 

The  thrombus  formed  under  such  conditions  differs  from  the  organized 
thrombus  at  the  seat  of  a  ligature,  inasmuch  as  the  passing  blood-current 
furnishes  fibrin-making  white  corpuscles  with  accompanying  fibrin-deposit 
in  the  one,  while  this  can  not  occur  after  a  ligature  is  applied. 

The  causes  of  thrombosis  may  be  summed  up  as  follows  :  1.  Occlusion 
of  the  vessel  as  by  a  ligature.  2.  Inflammation  of  the  intima  (arteritis). 
3.  Dilatation  of  the  vessels  (as  in  aneurism).  4.  An  abnormal  condition 
of  the  blood.  5.  Heart  failure.  6.  Narrowing  of  the  caliber  of  an  artery 
by  pressure. 

Vascular  Tumoes. 

We  may  recognize  six  varieties  of  vascular  tumor,  apart  from  true 
aneurism.  These  are :  1.  Arterial  varix ;  2.  Cirsoid  arterial  tumor,  or 
cirsoid  aneurism ;  3.  Arterial  cutaneous  tumor ;  4.  Capillary  cutaneous 
tumor ;  5.  Venous  cutaneous  tumor  (these  three  varieties  are  usually 
classed  together  under  the  name  of  angeiomata) ;  and  6.  Venous  varix, 
or  simply  varix  (varicose  vein). 

Arterial  Varix  may  be  defined  as  a  dilatation  and  elongation  of  an 
artery  of  the  second  magnitude  (as  the  external  iliac  or  common  carotid), 
of  the  third  (as  the  external  carotid  or  posterior  tibial),  or  of  the  fourth 
(as  the  temporal,  facial,  superior  thyroid,  or  palmar  branches  of  the  radial 
and  ulnar).  Cruveilhier  has  reported  a  case  of  arterial  varix  of  the 
external  iliac  artery.  I  have  made  one  dissection  of  arterial  varix  of  the 
superior  thyroid  artery,  in  which  this  vessel  was  greatly  elongated,  and 
as  large  as  the  external  or  internal  carotid.  It  was  tortuous,  but  not 
sacculated,  the  dilatation  being  general.  Tillaux*  reports  a  case  of 
cirsoid  aneurisvi  of  the  hand,  with  dilatation  of  the  arteries  of  the  fore- 
arm and  humeral  region. 

Treatment.  — Arterial  varix  may  be  treated  by  compression,  or  by  the 
ligature,  when  such  a  procedure  becomes  necessary.  In  a  case  which  I 
saw  after  the  patient's  death,  and  in  which  the  superior  thyroid  artery 
was  involved,  the  ligature  would  have  been  advisable.  The  artery  was 
in  a  healthy  condition,  with  the  exception  of  its  increased  length  and 
caliber. 

When  connected  with  cirsoid  arterial  tumors,  the  solidification  of 
these  by  ligature,  cautery,  or  injection,  will  usually  cure  or  palliate  the 
arterial  varix. 

Cirsoid  Arterial  Tumor,  or  Cirsoid  Aneurism. — The  cirsoid  arterial 
tumor  I  would  define,  after  Robin  and  Gosselin,  as  being  an  elongation 
and  dilatation  of  the  terminal  subcutaneous  arterioles  (normally  of  a 
diameter  of  about  one  fiftieth  of  an  inch).     These  tumors  may  be  general 

*  "Gaz.  des  h6pitaux,"  1882,  p.  1083. 


■  VASCULAR  TUMORS.  191 

or  circumscribed.  A  single  arteriole  may  be  affected,  as  shown  in  a 
drawing  in  the  Museum  of  St.  George's  Hospital,  copied  in  Holmes's 
"System  of  Surgery,"  or  many  arterioles  may  be  involved,  as  in  Mus- 
sey's  remarkable  case. 

The  term  cirsoid  aneurism  was  introdaced  by  Breschet,  in  a  paper 
presented  to  the  Academy  of  Medicine,  at  Paris,  in  1832.  By  him  it  was 
applied  to  the  condition  of  varicosity  involving  the  larger  arterial  trunks, 
their  branches,  and  the  terminal  arterioles.  Robin,  at  a  later  date,  intro- 
duced the  name  of  cirsoid  arterial  tumors,  and  defined  these  as  varicosi- 
ties of  the  tenninal  (subcutaneous)  arterioles.. 

English  writers  have  adopted  the  tenn  employed  by  Breschet.  By 
them  it  is  usually  considered  '"a  form  of  disease  which  consists  in  a 
simultaneous  elongation  and  dilatation  of  an  artery.  The  structure  of 
its  wall  exhibits  in  the  beginning  no  alteration,  although  the  coats 
become  thinned  during  the  progress  of  the  enlargement.  The  middle 
coat  of  the  artery  is  especially  affected.  It  becomes  pale  and  thin,  so 
that  the  arteries  look  like  veins.  The  dilatation  is  commonly  equal 
throughout  the  circumference  of  the  artery.  In  more  severe  cases  the 
artery  is  greatly  dilated,  and  presents  unequal,  saccular  pouches,  which 
are  in  fact  so  many  true  aneurisms,  projecting  usually  toward  the  surface 
of  the  skin  "  (Holmes). 

Grosselin*  adopts  the  nomenclature  of  Robin,  and  considers  the  dis- 
ease heretofore  known  as  cirsoid  aneurism  as  only  involving  the  terminal 
arterioles.  The  causes  of  cirsoid  arterial  tumors  are  not  positively 
known.  They  occur  most  frequently  upon  exposed  surfaces  of  the  body, 
as  on  the  neck,  head,  and  hands.  The  face  and  head  are  most  frequently 
the  seat  of  all  forms  of  vascular  subcutaneous  and  cutaneous  tumors. 
Excluding  those  of  the  orbit,  I  have  coDected  more  than  ninety  cases  in 
which  the  carotid  arteries  were  tied  for  these  lesions. 

Polaillon  reports  fourteen  cases  of  cirsoid  aneurism  of  the  hand.  The 
influence  of  exposure  of  an  unprotected  surface  to  atmospheric  changes 
is  worthy  of  consideration.  Either  peripheral  or  central  disturbances  of 
the  functions  of  the  vaso-motor  nerves  may  lead  to  loss  of  tone  in  the 
muscular  walls  of  the  arteries.  Frost-bite  and  blows  have  been  mentioned 
as  causes  of  cii'soid  aneurism.  Berger  reports  a  case  of  cirsoid  tumor  of 
the  hand  caused  by  irritation,  from  constant  pressure  of  an  instrument 
which  the  patient  used  in  his  trade.  The  disease  may  also  be  congenital, 
or  may  result  from  the  increased  growth  of  a  cutaneous  nsevus.  Gosselin 
cites  two  cases  of  this  kind.  He  holds  that  the  presence  of  nsevus  indi- 
cates a  congenital  predisposition  to  vascular  dilatation,  and  is  not  sure 
but  that  a  subcutaneous  arterial  dilatation,  at  first  not  recognized,  may 
exist  simultaneously. 

According  to  Holmes,  cirsoid  arterial  tumor  occurs  most  frequently 
between  the  ages  of  fifteen  and  thirty.  Wardrop's  patient,  whose  case  is 
given  by  Gosselin  as  one  of  cii'soid  arterial  growth,  was  operated  upon 
the  sixth  week  after  birth.     Wardrop  gives  the  case  as  one  of  "  erectile 

*  "Archives  g^nerales  de  medecine,"  1867. 


192  A  TEXT-BOOK  ON  SURGERY. 

tumor."  Chelius  operated  for  "  aneurismal  varix  of  the  temporal  region  " 
in  a  child  of  twelve  months. 

Symptoms. — The  clinical  history  of  cirsoid  arterial  tumors  does  not 
commence  with  the  pathological  changes  which  occur  in  the  terminal 
arterioles.  Dilatation  begins  before  there  is  any  appreciable  projection 
of  the  skin,  or  pulsation,  or  twisting  of  the  arterioles.  At  a  later  period 
the  physical  signs  are  present,  and  the  diagnosis  easy.  Direct  pressure 
will  ari'est  the  pulsation  and  empty  the  tumor.  The  consistency  of  these 
tumors  varies  with  the  amount  of  the  connective  tissue  developed  around 
the  arterioles,  as  a  result  of  the  inflammatory  process.  Petit  describes 
the  sensation  imparted  to  the  palm  of  the  hand  pressed  upon  an  arterial 
cirsoid  as  similar  to  the  vermicular  motion  of  a  mass  of  earth-worms. 

With  the  stethoscope,  a  bruit  de  souffle  is  distinctly  audible.  Pain  is 
not  constant,  and  is  only  due  to  the  pressure  of  the  growth  upon  the 
cutaneous  nerves.  As  the  tumor  progresses  in  size,  more  marked  inflam- 
matory changes  occur  ;  adhesions  to  the  skin  take  place  ;  and  ulcerations, 
with  alarming  hsemorrhages,  are  not  infrequent.  In  some  instances, 
especially  in  cirsoid  tumor  of  the  scalp,  pressure  of  the  growth  upon  the 
calvaria  may  interfere  with  the  nutrition  of  the  skull. 

Treatment. — It  maybe  said  of  the  treatment  of  cirsoid  arterial  tumors, 
in  common  with  arterial,  capillary,  and  venous  cutaneous  tumors,  that 
no  method  is  as  safe  or  sure  as  direct  local  treatment.  The  study  of  a 
large  number  of  cases  leads  me  to  this  conclusion.  For  a  long  time  deli- 
gation  of  the  main  trunk  or  trunks  was  the  favorite  practice.  Sometimes 
this  was  done  to  arrest  haemorrhage  due  to  ulceration  or  accident,  in  some 
few  cases  to  arrest  hgemorrhage  after  or  during  an  attempt  at  removal, 
but  most  frequently  the  intention  was  to  cut  ofi:'  the  blood-supply.  Since 
the  vast  majority  of  vascular  tumors  occupy  the  neck,  face,  and  scalp,  the 
carotids  have  been  often  tied  in  the  treatment  of  these  growths.  In  my 
"Essays  in  Surgical  Anatomy  and  Surgery"*  I  have  collected  98  cases 
of  ligature  of  the  carotid  for  vascular  growth  above  the  clavicle,  and 
chiefly  of  the  head.  This  number  does  not  include  60  cases  of  pulsating 
vascular  tumor  within  the  orbit.  The  results  are  not  such  as  to  encourage 
the  careful  operator  in  a  repetition  of  the  procedure. 

Even  in  the  nine  cases  in  which  both  common  trunks  were  tied,t  only 
one  was  cured  (not,  however,  until  after  comiaression  was  made  over  the 
tumor),  and  two  were  improved.  Mussey's  patient  was  only  improved 
after  the  second  ligation,  but  was  cured  after  a  bloody  excision.  The 
tumor  was  exceedingly  large,  and  the  dilated  arteries  were  tied  one  by 
one.  More  than  twenty  ligatures  were  applied,  and  the  hgemorrhage  is 
said  to  have  been  dangerously  profuse. 

Other  surgeons  besides  Mussey  %  who  have  practiced  excision  of  cir- 
soid arterial  and  other  "  vascular  tumors  "  are  Busch,:|:  Heine,  :j;  Graefe,* 

*  New  York,  1879. 

t  The  operators  were  Blackman,  Gnnderloch  and  Miiller,  Kubl,  Miissey,  Pirogoff,  Robert, 
Eodgers  and  Van  Biiren,  UJlman,  and  Warren. 

X  See  the  author's  "Essays  in  Surgical  Anatomy  and  Surgery,"  New  York,  1879. 

*  Holmes's  "  System  of  Surgery,"  second  edition,  vol.  iii,  p.  540. 


VASCULAR  TUMORS.  I93 

Gibson,*  BnchanaD,t  Sydney  Jones,:]:  Warren,*  Weitzer,*  Griieniot,*  and 
Hart.*  The  latter  froze  the  tumor,  and  cut  well  into  sound  tissue  ;  little 
blood  was  lost.  The  late  Prof.  Spence,  of  Edinburgh,  cured  a  deep-seated 
erectile  tumor  of  the  hand  by  galvano-puncture.  ||  Nelaton  operated  in 
a  cirsoid  tumor  of  the  forehead  in  a  similar  way,  and  with  like  success. 

Barwell  operates  upon  vascular  tumors  by  what  is  termed  the  scarless 
Tnethod.^  Having  carefully  made  out  the  limits  of  the  tumor,  a  needle 
armed  with  a  silver  wire  is  passed  under  the  skin,  and  subcutaneously 
around  the  outskirts  of  the  tumor,  to  a  point  opposite  the  place  of 
entrance.  The  needle  is  again  introduced  at  the  point  from  which  it  has 
just  emerged,  and  is  carried  around  the  remainder  of  the  tumor,  and  out 
at  the  first  point  of  entrance.  The  base  of  the  tumor  is  thus  looped  by 
a  wire  which  can  be  tightened  beneath  the  skin  at  will.  Barwell  uses  a 
slot  of  vulcanized  rubber,  which  he  slides  down  upon  the  wire  to  tighten 
it  around  the  tumor.  If  the  growth  be  very  large,  he  advises  the  needle 
to  be  brought  out  at  frequent  intervals. 

Direct  local  compression  has  been  tried  by  patient  and  expert  sur- 
geons, but  has  not  met  with  success. 

Gosselin^  in  his  classical  paper  reports  several  successful  cases  in 
which  he  employed  hypodermic  injections  of  perchloride  of  iron  into  the 
mass.  This  idea  was  original  with  Broca,  who  applied  the  styptic  ender- 
mically  with  success.  Pitha,  of  Prague,  and  Schuh,  following  Broca, 
thus  cured  three  cases  (Gosselin).  BergerJ  reports  a  case  of  cirsoid 
aneurism  of  the  hand  treated  by  this  method.  Velpeau,  Gherini,  and 
Demarquay  have  performed  the  same  operation.  In  Demarquay's  case, 
the  radial  and  ulnar  arteries  had  been  tied. 

The  method  of  procedure  is  as  follows :  The  tumor  must  be  com- 
pressed, so  that,  while  the  circulation  ceases,  the  growth  remains  full  of 
blood.  This  condition  must  be  maintained  for  at  least  ten  minutes  after 
the  injection.  The  syringe  being  filled,  the  air  is  carefully  excluded,  and 
the  needle  is  introduced  about  a  quarter  of  an  inch  into  the  mass,  when 
the  solntion  is  discharged.  Kneading,  to  disseminate  the  iluid,  is  then 
practiced,  and  the  iinger  is  placed  upon  the  hole  made  by  the  needle, 
or  the  needle  and  syringe  may  be  left  in,  during  the  ten  minutes. 

Pain  is  immediately  present,  and  persists  for  several  hours.  After  an 
interval  of  ten  or  fifteen  days,  the  operation  may  be  repeated,  if  neces- 
sary. Eight  or  more  operations  have  been  required  to  effect  a  final  cure. 
Ulcei'ation  may  follow,  but  it  is  usually  limited.  At  times,  unhealthy 
granulations  bud  up  from  these  ulcerating  patches,  requiring  repeated 
burning  with  nitrate  of  silver  or  with  the  actual  cautery. 

*  Holmes's  "System  of  Surgery,"  second  edition,  vol.  iii,  p.  540. 
t  "  British  Medical  Journal,"  June,  1875,  p.  835. 

I  "  Lancet,"  1882. 

*  See  the  author's  "Essays  in  Surgical  Anatomy  and  Surgery,"  New  York,  1879. 

II  "  Medical  Times  and  Gazette,"  Angust  21,  1875,  p.  209. 
■^  "Lancet,"  May  8,  1875,  p.  642. 

^  "  Archives  g6n.  de  ni^deoine,"  torn,  ii,  1867,  pp.  636-659, 
%  "  Gazette  des  hopitaux,"  1882,  p.  1082. 
13 


194  A  TEXT-BOOK   ON   SURGERY. 

In  one  of  Gosselin's  cases,  heemorrhage  was  so  frequent  and  persistent 
that  deligation  of  the  parent  vessel — the  femoral — was  at  one  time  con- 
sidered ;  but  this  was  happily  avoided  by  repeated  use  of  the  actual 
cautery.  * 

The  results  of  this  method  of  treating  cirsoid  vascular  tumors  are 
gratifying,  and  the  operation  is  worthy  of  repetition.  In  growths  of 
small  size  I  should  prefer  to  try  the  method  of  Barwell,  and,  if  this  failed, 
theu  the  injection  of  perchloride  of  iron  or  other  coagulating  solution. 
The  success  achieved  by  S]3ence  and  Nelaton  with  galvano-puncture  was 
such  as  to  justify  further  trial  of  this  method. 

Cases  of  spontaneous  cure  of  vascular  tumors  are  reported.  Dr. 
Krackowizer  presented  to  the  New  York  Pathological  Society  a  patient 
in  whom  pulsation  had  entirely  ceased  in  a  cirsoid  tumor  which  was 
contracted,  solid,  and  shriveled  at  various  points ;  the  peculiar  rustling 
noise,  also,  of  which  the  patient  had  complained,  was  now  entirely 
absent  when  he  was  quiet.  The  man  was  forty-five  years  of  age ;  the 
tumor  was  congenital,  and  had  grown  to  a  considerable  size,  but  without 
pain  or  haemorrhage.  Dr.  Krackowizer  referred  to  two  other  cases  re- 
corded by  Orfila  and  Chevalier. 

*  Gosselin's  cases  were  three  in  number: 

Case  I. —  Cirsoid  Arterial  Tumor  of  the  Left  Leg. — The  patient  was  a  woraan,  aged  twenty- 
five.  At  birth  she  had  a  small  red  stain  or  spot  in  the  skin  at  the  upper  and  anterior  part  of 
the  left  leg,  vvliieh  up  to  her  twelfth  year  had  grown  about  as  large  as  an  almond.  At  fifteen 
she  first  noticed  that  pulsation  began  in  it.  After  this  date  it  grew  more  rapidly,  projecting, 
however,  very  shglitly  from  the  surface,  until,  at  the  age  of  twenty-two,  it  began  to  ulcerate 
without  any  assignable  cause.  Hseinorrhage  occurred,  which  ceased  by  compression,  but  not 
until  syncope  had  ensued.  Repeated  bleedings  occurred  up  to  her  twenty-fifth  year,  when  the 
injections  were  commenced.  From  July  12th  to  August  23d,  seven  injections  were  made. 
Ulceration  began,  and  frequent  haamorrhages  occurred  between  October  12th  and  18th,  which 
were  arrested  by  the  actual  cautery  and  compression.  Cure  resulted  at  the  end  of  eleven 
months. 

Case  II. —  Cirsoid  Arterial  Tumor  of  the  Forehead  with  Arterial  Varices;  Hmmorrhage 
during  Many  Years;  Four  Injections  of  Perchloride  of  Iron  ;  Cure. — Patient  was  a  man,  aged 
thirty-nine ;  was  born  with  a  red  mark  on  his  forehead,  which  disappeared  at  his  tenth  year. 
About  nineteen  years  later,  when  in  his  twenty-ninth  year,  a  tumor  was  noticed  in  the  same 
place,  about  as  large  as  a  cherry-stone,  and  two  years  later  he  felt  it  begin  to  pulsate.  After 
that  time  it  continued  to  grow,  and  was  the  source  of  frequent  hasmorrhages  without  any 
direct  injury  or  known  cause.  The  patient  had  controlled  the  bleeding  by  compression.  At 
the  time  of  operation,  the  growth  was  about  two  inches  in  diameter,  and  projected  from  the 
skin  about  one  third  of  an  inch.  February  12th,  while  pressure  was  made  on  both  primitive 
carotids,  injections  were  made  with  two  syringes,  one  needle  being  introduced  on  each  side  of 
the  tumor.  The  compression  of  the  carotids  was  continued  ten  minutes.  The  tumor  still 
pulsated  at  points.  Compress  applied;  pain  was  severe  during  the  day  of  operation  and  the 
next  day  following.  Operation  repeated  on  the  1st  of  Marcli.  March  13th,  tumor  was  solid 
and  without  pulsation  throughout  two  thirds  of  its  extent.  Two  injections  made.  March  20th, 
tumor  began  to  ulcerate  at  two  limited  points,  which  were  soon  filled  with  exuberant  granula- 
tions. These  resisted  alcoholic  dressings  and  the  application  of  nitrate  of  silver.  March  24th,  • 
pulsation  reappeared  at  one  point,  and  the  injection  was  repeated.  May  20th,  the  granula- 
tions persisting,  actual  cautery  was  applied.  Same  on  -lune  6th.  July  8th,  patient  discharged, 
cured. 

Case  III  does  not  differ  materially  from  the  two  preceding  cases,  either  as  to  its  clinical 
history  or  as  to  its  treatment. 


VASCULAR  TTIMORS.  I95 

Angeiomafa. — The  three  next  varieties  of  "vascular  tumor,"  which 
may  be  grouped  together  under  the  name  of  Angeiomata,  are :  (1)  The 
Arterial  Cutaneous  Tumor,  or  Aneurism  by  Anastomosis,  composed  of 
dilatations  or  elongations  of  the  arterioles,  either  normal  or  new-formed, 
in  the  skin  ;  (2)  the  Capillary  Cutaneous  Tumor,  consisting  of  dilata- 
tions aud  elongations  of  the  normal  or  new-formed  capillaries  of  the  skin  ; 
and  (3)  the  Venous  Cutaneous  Tumor  {Cavernous  JVcevus),  composed  of 
dilatations  of  the  normal  or  new-formed  venous  radicles  of  the  skin. 

The  angeiomata  are  considered  by  some  writers  as  strictly  new-forma- 
tions of  blood-vessels.  There  is  little  doubt,  however,  that  many  vascular 
tumors  are  chiefly  made  up  of  normal  vessels  which  have  undergone 
dilatation  or  hypertrophy.  Other  names  that  have  been  given  to  angeio- 
mata are  congenital  nsevus,  erectile  tumor,  telangiectasis  or  ];)lexiform 
angeioma,  aneurism  by  anastomosis,  ecchymoma,  cavernous  naevus,  and 
fungus  hsematodes.  According  to  Depaul,  one  third  of  the  children  born 
in  one  of  the  eleemosynary  institutions  at  Paris  had  congenital  nsevi, 
the  greater  number  of  wliich  disappeared  spontaneously  during  the  first 
few  months  of  life.  They  occur  chiefly  in  the  skin,  and  are  especially 
apt  to  appear  on  the  forehead,  face,  ears,  and.  neck. 

Structure  and  Symptoms. — Angeiomata  commonly  form  flattened, 
slightly  projecting  tumors,  varjang  in  size  from  a  mere  speck  to  as  much 
as  an  inch  in  diameter,  and  are  composed  of  new-formed,  dilated,  freely 
anastomosing  capillaries,  arterioles,  and  veins,  in  irregular,  labyrinthine 
masses.  They  vary  in  color,  being  at  times  grayish-blue  or  red.  Often 
the  only  indication  of  their  presence  is  the  apj)earance  of  a  diffuse  red- 
ness over  a  considerable  surface.  Examined  microscopically,  the  avails 
of  the  vessels  are  crowded  with  cells,  and  the  vessels  are  imbedded  in  a 
network  of  fibrous  and  adipose  tissue.  The  superficial  and  deep  cutane- 
ous vessels — ^including  the  vessels  of  the  hair-foUicles,  sweat-glands,  and 
adipose  tissue — join  in  the  formation  of  these  tumors.  The  disease  may 
extend  into  the  muscles  and  deeper  tissues. 

The  majority  of  angeiomata  are  soft  and  yielding,  and  can  be  emptied 
by  pressure  ;  but  when  of  great  vascularity  and  long  standing,  when  there 
has  been  an  extensive  proliferation  of  the  perivascular  connective  tissue, 
pressure  will  not  cause  their  disappearance.  Some  are  very  painful,  and 
others  entirely  free  from  sensibility. 

Venous  cutaneous  tumors  are  composed,  in  great  part,  of  new-formed, 
erectile  tissue,  analogous  to  that  found  in  the  corpora  cavernosa.  Their 
structure  is  white  and  dense,  the  caverns  communicating  freely  with  each 
other.  In  rare  instances  they  are  known  to  contain  chalky  concretions, 
which  axe  known  as  pMebolites.  The  circulation  is  active  in  these 
tumors,  and  their  volume  variable. 

The  walls  of  the  sinuses  contain  a  dense,  fibrous  stroma,  involuntary 
muscular  tissue,  and  striated  muscular  fibers  when  the  tumor  is  encroach- 
ing on  the  muscles.  They  are  lined  by  the  same  endothelium  as  the 
normal  veins.  In  specimens  removed  and  immediately  immersed  in 
alcohol,  it  is  found  that  the  blood  presents  the  same  appearances  as  the 
normal,  with  the  exception  that  the  white  corpuscles  are  less  numerous 


196 


A  TEXT-BOOK   ON   SURGERY. 


Fio  267  — Cayernous  angeio:na  of  the  liver. 
Section  made  aftei  tbe  tumoi  had  been 
immediately  submerged  iia  alcohol,  a, 
cavernous  spaces  filled  with  blood-cor- 
puscles ;  h,  fibrous  walls  of  the  sinuses. 
Magnified  150  diameters.  (From  Cor- 
iiil  and  Kanvier.) 


(Fig.  267).  They  do  not  adhere  to  the  walls  of  the  vessels.  This  is  con- 
sidered as  proof  of  a  rapid  circulation,  since  in  veins  where  the  circulation 
is  weakened  or  retarded  the  leucocytes  tend  to  adhere  to  the  walls.  After 
excision,  the  vessels  contract,  forcing  out  their  contents,  and  the  mass 

shrinks  to  a  comparatively  small  size. 

These  tumors  are  not  all  erectile,  and 
some  which  have  been  erectile  for  a  time 
lose  this  property.  Gross  describes  a  f onii 
of  ngevoid  tumor  as  ncevoid  elephantiasis, 
consisting  of  a  hypertrophied  condition  of 
the  skin  and  subcutaneous  connective  tis- 
sue. The  affection,  which  is  either  con- 
genital or  comes  on  soon  after  birth,  is 
found  iisually  in  the  lower  extremities, 
thoiigh  it  may  occur  elsewhere. 

The  theories  as  to  the  origin  of  these 
neoplasms  are  various.  Some  hold  that 
simple  dilatation  of  contiguous  veins  oc- 
curs when,  the  sacculated  vessels  coming 
in  contact,  the  walls  are  absorbed,  and 
thus  many  cavities,  which  formerly  were 
separate,  may  form  one  or  more  large, 
multilocular,  cavernous  tumors.  These 
dilatations  occur  not  only  in  the  skin  and 
subcutaneous  tissues,  but  also  in  bone  and 
muscle.  No  tissue  can  be  considered  exempt.  Rokitansky  holds  that 
they  originate  ia  the  areolar  tissue,  from  embryonic,  new-formation  tis- 
sue, and  that  the  vascularization  of  this  new  tissue  is  one  of  the  last 
processes  of  its  development.  He  compares  the  alveoli  of  the  cavernous 
angeioma  to  those  of  carcinoma. 

Rindtleisch  believes  that  the  appearance  of  these  tumors  is  preceded 
by  a  proliferation  of  embryonic  material  in  the  intervascular  spaces,  and 
that  this  material,  undergoing  the  usual  process  of  cicatrization  and  con- 
traction, causes  a  shrinkage  in  the  intervascular  areas,  when  the  vessels 
dilate  to  occupy  the  space  left  vacant  by  the  contracting  tissues  (Billroth). 
Cornil  and  Ranvier  say  that  in  the  active  development  of  angeiomata 
there  is  a  proliferation  of  embryonic  tissue,  rich  in  new-foi"med  vessels, 
which,  increasing  rapidly  in  size,  come  in  contact  and  communicate  with 
each  other  by  absorption  of  contiguous  surfaces. 

Angeiomata  may  develop  in  fatty  and  other  neoplasms.  Billroth 
mentions  a  case  in  which  a  large  cavernous  angeioma  was  found  in  a 
lipoma  removed  from  the  scapular  region.  They  have  been  known  to 
originate  as  a  result  of  injury.  Gross  cites  a  case,  reported  by  Dr.  J. 
Mason  Warren,  of  a  man  thirty-six  years  old,  who  had  a  large  aneurism 
by  anastomosis,  situated  on  the  lobe  of  the  ear,  which  res\ilted  from  a 
frost-bite  which  the  patient  had  suffered  in  his  sixteenth  year.  In  addi- 
tion to  the  tissues  already  mentioned  in  which  angeiomata  are  developed 
may  be  mentioned  the  spleen,  kidney,  liver,  and  lung.     The  liver  is  fre- 


VASCULAR   TUMORS. 


197 


-Aneurism  by  anastomosis  in  parietal  bone. 
(Erichsen.) 


qiiently,  the  lung  very  rarely,  involved.  In  bones,  this  disease  exhibits  the 
same  erectile  characters  as  in  other  structures  (Fig.  268).  It  occurs  in  the 
flat  bones  by  preference,  especially  those  of  the  cranium,  jaws,  and  scapula, 
being  often  very  painful,  and  grave  as  to  prognosis.  Angeiomata  are  not 
infrequently  situated  on  the 
labia  of  women.  Holmes 
Coote  has  observed  serous 
cysts  in  connection  "with 
these  vascular  growths.  An 
explanation  of  their  forma- 
tion is,  that  communication 
of  a  portion  of  one  dilated 
vessel  with  other  vessels  is 
cut  oif,  and  that  the  corpus- 
cles and  coloring  matter  of 
the  blood  disappear,  the  se- 
rum remaining  as  a  cystic 
fluid. 

The  question  of  the  rela- 
tion of  these  tumors  to  carcinomata  and  sarcomata  is  worthy  of  consider- 
ation. J.  Muller  has  reported  a  malignant  (recurrent)  angeioma.  A  case 
of  melanotic  degeneration  of  a  congenital  n?evus  in  a  woman  aged  forty 
has  been  reported  by  Dr.  Styles.  The  vascular  dilatations  in  osteo-sarco- 
mata,  and  in  other  fonns  of  carcinoma  and  sarcoma,  are  analogous  to  those 
found  in  cavernous  angeiomata.  Some  of  the  malignant  tumors  pulsate 
like  the  angeiomata.     An  angeioma  may  be  diffuse  or  encapsulated. 

The  jJ'i'ognosis  depends  upon  the  size  and  location  of  the  neoplasm. 

The  diagnosis  is  not  difficult  in  the  superficial  tumors,  but  in  those 
deeply  situated,  and  in  the  track  of  large  vessels,  the  differentiation  from 
aneurism  is  not  easy. 

The  arterial  and  capillary  cutaneous  tumors  are  almost  always  con- 
genital ;  the  venous  tumors  are  rarely  so.  Angeiomata  may  be  distin- 
guished from  osteo-sarcomata,  which  have  perceptible  pulsation,  by  the 
crackling  impression  conveyed  to  the  sense  of  touch  fi'om  the  malignant 
tumors  of  bone. 

Several  consecutive  telangiectases  may  occur  in  the  same  individual. 
Hutchinson,  of  London,  reports  the  case  of  a  child  which  had  over  one 
hundred  n8e^'i,  all  distinct  and  superficial.  Vascular  tumors  on  the  scalp 
have  an  element  of  danger  not  present  in  angeiomata  elsewhere,  in  that 
they  at  times  gTow  to  such  an  extent  as  to  cause  necrosis  of  the  calvaria. 

Treatment. — Angeiomata  have  been  known  to  heal  without  surgical 
interference,  as  a  result  of  an  idiopathic  inflammation.  Transfixion  and 
multiple  deligation  is  one  of  the  most  radical  and  successful  methods  of 
treatment.  Direct  and  prolonged  pressure  has  been  employed,  though 
not  with  encouraging  results.  Perforation  with  hot  needles,  either  with 
or  without  the  galvanic  current,  injection  of  coagulating  fluids,  jiarticu- 
larly  Monsel's  solution,  50  per  cent  carbolic  acid,  or  of  ergot,  local  appli- 
cations of  nitric  acid  or  other  escharotics,  and  extirpation  by  the  knife. 


198  A  TEXT-BOOK   ON  SURGERY. 

have  all  been  practiced.  Vaccination  over  the  growth  has  effected  a  cure 
in  a  few  cases. 

In  treating  superficial  angeiomata,,  not  too  extensive,  and  not  situated 
where  the  cicatrix  would  prove  a  deformity,  50  per  cent  carbolic-acid  in- 
jections may  be  employed.  In  many  cases  coagulation  of  the  blood- 
contents  and  ultimate  absorption  will  occur  without  a  scar.  A  quicker 
method  of  cure  is  removed  with  the  knife,  the  incision  extending  well  away 
from  the  margins  of  the  tumor  in  healthy  tissues.  Hsemorrhage  is  to  be 
controlled  by  pressure,  rapid  use  of  forceps,  or  preliminary  ligature. 

Angeioma  of  the  face,  or  of  any  exposed  surface  where  a  scar  is  to  be 
avoided,  is  best  relieved  by  the  clean  cut  of  the  knife,  since  the  cicatrix 
is  less  deforming  than  that  produced  by  other  modes  of  treatment.  I 
have  removed  a  number  of  these  growths  from  the  scalp  and  face.  The 
incision  should  be  made  one  fourth  of  an  inch  from  the  edge  of  the 
tumor,  cutting  only  through  healthy  tissue.  When  this  precaution  is 
taken,  hsemorrhage  is  not  dangerous.  Of  course  the  operation  is  not 
justifiable  if  telangiectasis  involves  more  surface  than  can  be  covered  by 
stretching  or  sliding  the  sound  integument,  or  when  it  requires  removal 
of  the  eyelid,  ala  nasi,  or  too  much  of  the  lip  or  ear.  In  such  instances 
galvano-cautery  needles  or  frequent  and  limited  injections  should  be 
employed.  In  cavernous  tumors  of  large  size  the  following  method, 
recommended  by  Prof.  Esmarch,  of  Kiel,  may  be  successfully  employed  : 

Immerse  a  middle-sized  silk  thread  for  one  half  hour  in  tinct.  ferri. 
chlor. ;  remove  and  dry.  A  round,  straight,  or  slightly  curved  needle  is 
armed  with  this  thread  and  passed  through  the  tumor  in  all  directions 
at  intervals  of  about  one  fourth  of  an  inch.  The  first  series  of  threads 
should  be  passed  through  the  deeper  portions  and  parallel.  If  the  ncevus 
is  considerably  elevated,  a  second  layer  should  be  inserted  at  a  right 
angle  to  the  first.  The  threads  are  cut  off  a  half-inch  from  the  surface 
of  the  tumor  and  left  in  position.  A  light  sublimate  or  carbolated 
gauze  dressing  should  be  laid  on,  and  over  this  a  layer  of  borated  cot- 
ton, held  in  place  without  too  much  compression  by  a  bandage. 

In  from  two  to  four  days  complete  coagulation  occurs  and  the  threads 
are  to  be  removed.  If  absorption  is  not  rapid,  the  coagulated  mass  may 
be  removed  by  dissection.  By  this  procedure  I  succeeded  in  consolidat- 
ing and  removing  an  enormous  cavernous  ngevus  of  the  face.  Tlie  disfig- 
urement was  very  slight. 

Venous  Varix,  Van' x,  or  Varicose  Vein. — This  variety  of  "  vascular 
tumor"  consists  of  a  dilatation  and  elongation  of  the  deep  or  subcutane- 
ous veins.  This  condition  may  exist  in  any  i^ortion  of  the  body,  even  in 
the  bones  (Cornil  and  Ranvier).  It  may  involve  a  small  portion  of  one 
vein,  superficial  or  deep,  or,  as  is  most  usual,  a  chain  of  veins.  It  is  most 
frequently  observed  in  the  superficial  veins,  though  Verneuil  says  that 
varix  is  really  as  common  in  the  deep-seated  as  in  the  superficial  vessels 
(Bryant).  It  is  especially  prone  to  occur  in  the  saphena  veins.  Hgemor- 
rhoids  and  varicoceles  are  common  forms  of  varix.  Unusual  types  are 
the  dilatation  of  the  jugulars  from  stenosis  of  the  vena  cava  descendens, 
and  that  of  the  suxDerficial  abdominal  veins  from  stenosis  of  the  ascending 


VASCULAR  TOIORS. 


199 


cara.  Snch  conditions  are  described  by  some  authors  as  simple  hyper- 
trophies  or  dilatations  of  reins.  Any  long-continned  dilatation  consti- 
tutes a  varix.  Hyperplasia  of  the  nonnal  tissues  of  the  venous  wall  is 
the  natural  sequence  of  prolonged  pressure  and  increased  function.  The 
hypertrophy  of  the  wall  is  not  always  equal  to  the  resistance  of  the  in- 
creased pressure  ;  hence  sacculated  pouches  occur  when  the  vessel-wall 
becomes  much  thinner  than  normal,  not  infrequently  resulting  in  rupture. 
Yarix  is  of  frequent  occurrence  in  women  who  have  had  repeated  preo'- 
nancies  (Billroth). 

Poorly-fed  and  hard-worked  persons,  especially  those  who  work  in 
the  upright  i)ostxrre,  are  more  prone  to  varix  than  others.  There  can  be 
no  doubt  that  gravitation  is  the  chief  and  immediate  cause  of  this  disease. 
The  veins  most  subject  to  the  greatest,  prolonged  blood-weight,  and  least 
protected  by  pressure,  are  involved  in  the  great  majority  of  cases.  Pa- 
ralysis of  the  muscular  walls,  either  by  atrophy  of  the  muscles  or  inter- 
ference with  the  function  of  the  nervi  vasorum,  may  cause  varix.  This  is 
proved  by  the  fact  that  a  small  segment  of  a  single  vein  in  the  upper  por- 
tion of  the  body,  where  the  anastomosis  is  free  and  gravitarion  can  not  be 
considered  as  a  factor  in  the  dilatation,  may  be  the  seat  of  this  affection. 

In  well-marked  varix  the  veins  are  greatly  increased  in  caliber  and 
in  length,  so  that  they  seem  coiled  and  twisted  upon  themselves  in 
knotted  masses.  They  are  naiTowed  in  caliber  at  fi'equenr  intervals, 
these  contractions  opening  into  expanded  pouches,  in  general  appearance 
not  unlike  the  sacculated  large  intestine.  The  valves  are  wholly  ineffi- 
cient, often  flattened  against  the  wall,  or  at  times  partially  destroyed. 
At  the  level  of  the  valves  the  walls  are  exceptionally  thickened.  The 
thickening  is  due  to  a  multiplication  of  the  muscular  elements  and  hyper- 
plasia of  the  connective  tissue.  The  connective-tissue  new  formation  is 
abundantly  disti-ibuted  in  the  meshes  of  the  elastic  net-work,  and  the 
bundles  of  fibers  are  usually  arranged  parallel  vdih  the  long  axis  of  the 
vessel.  This  accounts  for  the  longitudinal  ridges  seen  on  the  inner  sur- 
face of  the  affected  veins  (Cornil  and  Eanvier).  Even  the  nutrient  vessels 
of  the  walls  of  these  varicose  veins — the  vasa  tasorum — ^have  undergone 
hypertrophy,  and  are  themselves  the  seat  of  varix,  foiTuing  at  times 
venous  caverns  in  the  wall  of  the  vessel,  which  communicate  vdth  the 
vein.  The  internal  tunic  is  not,  properly  speaking,  thickened,  except  at 
the  points  of  attachment  of  the  valves,  or  when  a  thrombus  has  formed. 

Immediately  external  to  the  middle  elastic  tunic,  the  muscular  tissue 
appears  increased  in  quantity,  arranged  in  transverse  and  j^erj^endicular 
laminae,  separated  by  bundles  of  hypertrophied  connective  tissue,  which 
are  not  infrequently  stained  with  granular  pigment.  Calcareous  deposits 
occur  primarily  within  or  between  these  connective-tissue  bundles  (CornD. 
and  Ran\aer).* 

Hyperplasia  of  the  connective  and  other  tissues  in  the  immediate 
vicinity  of  a  varix  of  long  standing  presents  the  usual  appearances  of 

*  In  the  arteries,  these  deposits  occur  first  around  and  within  the  nneleus  of  the  nnstriped 
masoje,  and  gradually  increase  until  they  fill  the  cell,  which  becomes  converted  into  a  small 
calcareous  fiake  (Green).     See  section  on  "Arteritis." 


200  A  TEXT-BOOK   ON   SURGERY. 

elephantiasis.  Small  spots  of  ulceration  occur  as  a  result  of  malnutri- 
tion, and,  coalescing,  form  the  large  and  obstinate  ulcers  seen  so  fre- 
quently in  varix  of  the  legs.  The  veins  become  greatly  elongated  and 
assume  different  shapes,  irregularly  sinuous  or  corkscrew-like,  twisted 
upon  their  axes,  and  frequently,  on  account  of  perivascular  inflam- 
mation, matted  together  by  new-formed  connective  tissue  into  venous 
tumors.  Occlusion  of  varicose  veins  may  result  from  thrombosis,  and 
a  cure  may  thus  ensue.  Frequently  concretions  are  found  in  varicose 
veins,  at  times  adherent  to  the  walls.  These  concretions  are  called 
pJilebolithes  or  pJilebolites  (Dunglison).  They  are  laminated  on  sec- 
tion, and  are  said  to  contain  by  analysis  20  per  cent  of  protein  matter, 
vith  phosphate  and  sulphate  of  lime  and  sulphate  of  potassium  (Frank- 
lin and  Bryant),  and,  according  to  Gross,  a  trace  of  oxide  of  iron. 
They  are  found  most  frequently  in  the  veins  of  the  pelvis,  about  the 
bladder  and  prostate,  especially  when  the  latter  is  enlarged.  Hodgson 
says  that  they  are  formed  in  other  tissues,  and  work  their  way  into  the 
vessels.  This  theory  would  seem  to  receive  a  partial  support  from  the 
statement  just  made,  that  they  are  most  frequently  found  near  the  pros- 
tate, and  when  this  organ  is  diseased.  It  is  well  known  that  small 
calculi  are  frequent  in  this  body.  Phlebolites  are  also  found  in  veins 
not  subject  to  varix.  Cruveilhier  believed  that  they  were  developed 
from  coagula  (Holmes). 

Treatment. — Varicose  veins  are  to  be  treated  chiefly  by  artificial  sup- 
port to  the  weakened  and  dilated  walls.  Eczema  and  the  various  forms 
of  ulcer  occurring  in  connection  with  varix  are  relieved  by  proper  sup- 
port. The  varix,  however,  is  not  often  cured  by  this  means  alone,  which 
is  merely  palliative.  Martin's  elastic  bandage  is  of  great  use.  Band- 
ages of  muslin  or  flannel,  properly  applied,  give  great  relief.  The  elastic 
silk  apparatus,  for  constant,  equable  pressure,  cleanliness,  and  comfort, 
can  not  be  surpassed  in  the  treatment  of  varix.  The  relief  of  j)ressure 
by  position  is  always  advisable.  All  supporting  apparatus  should  be 
removed  at  bedtime  and  adjusted  before  rising.  The  only  method  of 
radical  cure  is  by  occlusion.  The  use  of  a  subcutaneous  catgut  ligature, 
passed  at  several  points  under  and  not  through  the  veins,  is  the  most 
approved  method.  With  careful  antisepsis  and  the  use  of  cocaine  this 
procedure  is  painless  and  not  dangerous.  The  cases  are,  however,  ex- 
ceedingly rare  where  such  procedures  are  necessary. 


Moles. 

Closely  connected  with  the  more  superficial  forms  of  vascular  tumor 
are  the  abnormal,  circumscribed  hypertrophies  of  the  skin,  which  are 
known  as  moles.  They  may  be,  and  usually  are,  congenital,  or  they 
may  be  developed  at  any  period  of  extra-uterine  life.  All  portions  of 
the  cutaneous  surface  may  be  the  seat  of  this  form  of  hypertrophy,  but 
the  exposed  surfaces,  such  as  the  face,  neck,  and  hands,  are  most 
frequently  affected.     The  hypertrophy  which  constitutes  the  mole  may 


MOLES.  201 

involve  all  or  any  one  of  the  tissues  vrhich  entei'  into  the  anatomy  of 
the  integument.  The  most  frequent  variety  is  that  which  occupies  the 
face,  as  a  simple  elevation  from  which  a  few  stiff  hairs  grow.  It  is  not 
stained  with  pigment,  and  differs  very  slightly,  if  at  all,  in  color  from 
the  normal  skin.  The  lesion  here  is  a  true  hypertrophy  of  all  the  tis- 
sues of  the  skin,  chiefly  in  the  derma  and  papillary  layer.  The  vascu- 
larity is  slightly  increased,  and  the  sebaceous  glands  connected  with  the 
hair-follicles  take  part  in  the  hypertrophy.  On  other  portions  of  the 
body  this  form  of  mole  {ncevus  vulgaris)  will  have  no  hairs  growing 
from  its  surface. 

JVcEDUs  pigmentosus  is  not  usually  a  thickening  of  the  entire  cutis,  as 
is  the  simj)le  mole  just  described,  but  its  pathological  condition  is  an 
excessive  deposit  of  pigment  in  the  Malpighian  layer  and  in  the  epider- 
mis. It  varies  in  color  from  a  slate-gray  to  a  blue,  mahogany,  reddish- 
brown,  or  wine-color.  At  times  the  pigment  mole  will  extend  over  a 
large  area,  occupying  as  much  as  one  thii'd  or  one  half  of  the  face. 
The  lobule  of  the  ear,  and  the  integument  between  the  eyes  and  over  the 
temjjle,  is  the  most  common  location  of  this  deformity.  Another  name 
for  these  spots  is  ^^ port-wine  marTiy 

When  the  hypertrophied  area  of  skin  is  studded  with  hairs,  it  is 
known  as  nxEtus  pilosus,  or  hairy  mole.  It  foEows  from  the  name  that 
this  form  of  hypertrophy  can  only  occur  on  those  portions  of  the  cutis 
in  which  the  hairs  grow.  The  plantar  surfaces  of  the  feet  and  the  palms 
of  the  hands  are  never  affected.  They  may  or  may  not  be  stained  with 
pigment.     The  majority  of  hairy  moles  are  not  colored. 

Moles,  whether  simple,  hairy,  or  pigmented,  are  benign.  As  a  result 
of  irritation,  they  may  inflame  and  become  ulcerated,  or  may  develop 
into  malignant  gTowths.  Carcinomata,  especially  of  the  melanotic  variety, 
are  frequently  described  as  having  resulted  from  inflamed  pigment  moles. 
Alarming  haemorrhage  has  been  known  to  occur  from  a  mole  more  than 
usually  vascular,  in  which  ulceration  had  been  established  by  friction  of 
the  clothing. 

Treatment. — As  long  as  no  deformity  or  inconvenience  results  from, 
these  formations,  it  is  better  to  let  them  alone.  When  situated  upon  the 
face,  of  such  size  or  position  that  they  become  offensive  to  the  eye,  they 
may  be  removed  by  simple  excision.  The  incision  should  be  elliptical, 
and  well  away  from  the  growth,  going  entirely  through  the  thickness  of 
the  skin.  The  wound  should  be  closed  with  fine  sutures,  or  drawn 
nicely  together  with  adhesive  strips.  The  simplest  method  of  procedure 
is  to  produce  local  anaesthesia  by  cocaine,  and  operate  quickly.  Port- 
wine  marlis  may  also  be  excised. 

If  a  mole  should  at  any  time  take  on  inflammatory  action,  or  give  any 
indication  of  malignant  proliferation,  immediate  excision  would  be  im- 
perative, and  the  incision  should  be  wide  of  the  supposed  area  of  the 
disease.  The  employment  of  caustics  or  irritants  of  any  kind  is  to  be 
deprecated,  as  they  would  increase  the  tendency  to  malignant  change  in 
these  growths. 


CHAPTER  X. 


ANEURISM. 


eR 


Aw  aneurism  is  a  sacculated  tumor,  the  cavity  of  which  communicates 
with  an  artery,  and  in  rare  instances  also  with  a  vein. 

They  may  be  classified  as  spherical,  fusiform,  and  dissecting. 
A  spherical  aneurism  is  one  in  which  the  tumor  is  well  defined,  the 
diameter  of  its  cavity  being  larger  than  the  diameter  of  the  opening  of 
communication  with  the  vessel.     It  may  spring  from  any  portion  of  the 

arterial  wall  (Fig.  269,  e),  or,  in 
rare  instances,  the  vessel -walls 
may  yield  in  all  directions  to 
form  the  tumor  (Fig.  269,  c). 

A  fusiform  aneurism  is  one 

in  which  there  is  a  gradual  and 

general  dilatation  of  an  artery  in 

its     entire     circumference     (Fig. 

269,  a.  It).     A  spherical  aneurism 

Fig.  269.  may    occasionally   develop    from 

the  wall  of  a  fusiform  dilatation. 

A  dissecting  aneurism  is  one  in  which,  owing  to  pathological  changes 

in  the  intima,  with  necrosis,  the  blood  insinuates  itself  between  the  inner 

coat  and  the  adventitia,  dissects  the  intima  from  the  media  and  adven- 

titia,  and  re-enters  the  vessel  at  a  distant  opening. 

Aneurisms  are  further  divided  into  the  ti'ue  and  false.  To  the  former 
belong  all  tumors  the  walls  of  which  are  composed  of  the  walls  of  the 
vessels  from  Avhich  they  spring  ;  to  the  latter  belong  those  tumors  the 
walls  of  which  are  composed  of  inflammatory  new-formed  tissue. 

Cause. — A  true  aneurism  is  always  preceded  by  arteritis,  which 
results  in  atheromatous  degeneration  of  the  normal  elements  which 
compose  the  arterial  wall. 

The  pathology  of  arteritis  and  the  relation  of  this  condition  to  various 
dyscrasise — as  syphilis,  nephritis,  gout,  rheumatism,  etc. — have  been  fully 
dwelt  on  in  a  preceding  chapter.  These  are  among  the  diseases  which 
are  favorable  to  the  development  of  aneurism.  The  relation  of  violence 
to  these  tumors  must  not  be  lost  sight  of.  ISTo  matter  how  sevei'e  the 
dyscrasia  and  the  general  condition  of  arteritis,  which  is  a  part  of  it,  it 
is  well  known  that  in  the  large  majority  of  cases  aneurisms  develop  at 
those  points  in  the  arterial  system  which  are  subjected  to  the  greatest 


ANEURISM. 


203 


violence  from  lieari -action,  or  muscular  or  mechanical  pressure.  Thus 
the  arch  of  the  aorta,  and  that  portion  of  the  arch  in  the  direct  axis  of 
the  left  ventricle,  is  very  prone  to  aneurism,  as  are  the  great  vessels  near 
their  origin  from  the  aortic  curve.  The  popliteal  arteries,  subjected  as 
they  are  to  violence  in  forced  flexion  of  the  legs,  are  frequently  the  seat 
of  aneurismal  dilatations. 

From  a  study  of  the  various  conditions  which  produce  aneurisms,  it 
is  e^-ident  that  the  normal  wall  of  an  artery  can  not  form  the  sac  of  the 
aneurism.  Some  of  the  normal  anatomical  elements  may  be  present  in 
the  sac,  but  the  integrity  of  the  whole  is  impaired  ;  and  it  may  be  that,  in 
the  progress  of  an  aneurism  which  began  in  atheromatous  degeneration  of 
a  part  of  the  elements  of  the  vessel-wall,  all  of  these  elements  will  eventu- 
ally disappear,  being  replaced  by  an  inflammatory  new  formation. 

A  sacculated  aneurism  may  in  rare  in- 
stances communicate  with  a  vein  {varicose 
aneurism)  (Fig.  270).  The  direct  commu- 
nication of  a  vein  and  artery  without  a  sac 
is  known  as  aneurismal  varix  (Fig.  271). 

If  an  aneurismal  tumor  be  examined,  it 
will  be  found  to  contain  coagulated  blood 
in  all  stages  of  fibrillation.  The  peripheral 
portion  of  the  clot  is  composed  of  irregu- 
lar laminfe,  and,  if  examined  uith  the  mi- 
croscope, the  laminated  appearance  is  found 
to  be  due  to  alternate  layers  of  white  cor- 
puscles, and  upon  these  a  deposit  of  fibrin 
(a   condition   which   goes   to   sustain    the 

theory  of  A.  Schmidt,  ah'eady  cited,  that  fibrin  fennent,  the  coagu- 
lation factor  of  the  blood,  is  resident  in  the  leucocytes).  As  the  center 
of  the  tumor  is  api^roached,  the  coagulation  is  evidently  more  recent, 
while  in  the  cavity  of  the  aneurism  a  soft  post-mortem  clot  is  usually 
found. 

Fusifurm  aneurism  occurs  most  frequently  in  the  thoracic  aorta,  with 
especial  preference  for  the  arch.  It  may  affect  the  entire  aorta,  and  the 
great  vessels  derived  from  it.  Wot  only  is  the  diameter  of  the  arteries 
increased,  but  the  hypertrophy  results  in  a  considerable  increase  in  their 
length.  JSTot  infrequently  a  group  of  fusifoim  expansions  may  be  seen 
with  strips  of  sound  and  non-dilated  artery  intervening.  Calcareous 
deposits  occur  in  patches,  and  seem  to  give  strength  to  the  walls,  since 
those  portions  give  way  more  readily  which  are  not  the  seat  of  calcifica- 
tion. 

Coagulation  is  not  apt  to  occur,  as  in  sacculated  aneurisms  ;  in  fact,  it 
is  a  rare  condition.  Fusiform  aneurisms  develop  slowly,  and,  as  a  rule, 
are  painful  and  dangerous  only  when,  by  reason  of  their  large  growth, 
they  exercise  undue  pressure  upon  important  organs.  Thus,  in  dilata- 
tion of  the  transverse  arch,  or  of  the  right  subclavian,  spasm  of  the 
glottis  occurs  from  irritation  of  the  recurrent  laryngeal  nerves,  or  respi- 
ration and  deglutition  may  be  seriously  embarrassed  by  direct  compres- 


FiG.  270. 
Varicose  aneurism. 


Fio.  271. 
mrismal  varix. 


204  A  TEXT-BOOK  ON   SURGEKY. 

sion  of  the  trachea  or  oesophagus.  Fusiform  dilatation  of  the  abdominal 
aorta  may  produce  serious  resiilts  from  disturbance  of  the  vaso-motor 
system,  by  compression  of  the  sympathetic  ganglia  near  the  diaphragm, 
by  partial  or  complete  occlusion  of  the  thoracic  duct,  etc. 

Dissecting  aneurisms  are  rare  as  compared  with  the  other  two  varieties. 
The  dissection  or  lifting  of  the  thin  lining  membrane  of  the  artery  from 
the  media  usually  occurs  in  the  long  axis  of  the  vessel.  If  the  middle 
and  outer  coats  do  not  become  involved  in  the  degeneration  which  has 
affected  the  inner  coat,  this  form  of  aneurism  may  continue  indefinitely, 
without  leading  to  a  fatal  termination,  although  the  danger  of  embolism 
can  not  be  overlooked. 

If  the  other  layers  give  way,  a  sacculated  aneurism  is  formed,  with  the 
adventitia  for  the  sac,  or  rupture  may  occur,  leading  to  fatal  extravasa- 
tion. 

X  false,  or  so-called  '■'■diffuse,''^  aneurism  results  from  the  solution 
of  continuity  in  all  the  coats  of  the  vessel-wall,  and  the  sudden  diffu- 
sion of  blood  into  the  peri -arterial  tissues.  The  extravasation  con- 
tinues until  the  resistance  of  the  surrounding  tissues  is  equal  to  the 
pressure  of  the  column  of  blood  within  the  vessel.  As  a  result  of  the 
extravasation,  an  inflammatory  process,  of  variable  intensity,  is  estab- 
lished, which  results  in  the  formation  of  a  limiting  membrane,  or  aneu- 
rismal  sac. 

The  prognosis  in  aneurism  varies  under  widely  differing  conditions. 
In  general  it  is  a  grave  affection,  the  gravity  depending,  in  a  great  de- 
gree, upon  the  location  and  character  of  the  tumor  and  the  physical  con- 
dition of  the  individual  affected.  An  aneurism  of  the  cranial  cavity  will 
produce  rapidly  serious  effects  by  compression  of  the  brain.  The  gravity 
of  a  prognosis  diminishes  as  the  location  of  the  tumor  is  removed  from 
the  cavities.  Aneurism  (especially  the  sacculated  variety)  of  the  aorta, 
innominate,  subclavian,  or  iliac  arteries,  is  an  exceedingly  dangerous 
affection,  while  the  same  condition  in  the  distal  arteries  yields  readily 
and  safely  to  surgical  interference  in  the  great  majority  of  cases.  The 
prognosis  may  also,  in  part,  depend  upon  the  degree  of  discomfort  expe- 
rienced by  the  patient,  from  the  effects  of  pressure  upon  contiguous 
organs.  Neuralgia  of  the  most  painful  and  obstinate  kind,  resulting 
from  pressure  of  the  tumor  upon  a  neighboring  nerve,  may  hasten  a  fatal 
termination  by  loss  of  sleep  and  rest,  and  the  general  impairment  of 
nutrition.  Occlusion  of  the  accompanying  vein  may  occur,  producing 
oedema  and  gangrene.  Again,  the  gravity  of  the  prognosis  is  increased 
when,  by  reason  of  its  location,  the  sac  of  an  aneurism  is  in  contact  with 
a  bony  surface,  since  rupture  is  not  infrequently  precipitated  by  attrition 
against  the  roughened  bone. 

The  symptoms  of  aneurism  are,  in  great  part,  local.  They  refer  to  the 
direct  development  and  effect  of  the  tumor.  A  sense  of  unusual  throb- 
bing pain,  more  or  less  severe,  and  swelling  in  the  line  of  an  artery  (when 
the  aneurism  is  outside  of  a  cavity)  which  pulsates  with  the  cardiac 
systole,  which,  when  not  resting  upon  a  hard  surface,  is  expansile  in  all 
directions,  and  which  gives  to  the  sense  of  touch  a  tremor  not  easily 


ANEURISM.  205 

described  but  readily  appreciated,  are  symptoms  which  point  in  general 
to  the  diagnosis  of  aneurism.  The  stethoscope,  applied  to  the  tumor, 
conveys  to  the  ear  the  peculiar  sound  {'' bruit '")  caused  by  the  passage 
of  the  blood-current  from  the  narrow  vessel  into  the  expanded  aneurismal 
sac  and  out  again.  If  the  tumor  be  situated  upon  one  of  the  arteries  of 
the  extremities,  compression  upon  the  cardiac  side  will  cause  a  cessation 
of  the  pulse-tremor  and  bruit,  and  diminution  of  the  swelling,  while 
pressure  upon  the  distal  side  will  temporarily  exaggerate  these  symp- 
toms. 

When  an  aneurism  is  developed  as  a  result  of  a  wound  of  an  artery, 
the  immediate  symptoms  of  haemorrhage  and  swelling,  with  the  pulsat- 
ing character  of  the  tumor,  will  clearly  indicate  its  presence.  The  differ- 
entiation is  chiefly  between  solid  or  cystic  tumors,  which  develop  along 
the  line  of  the  artery,  and  are  Kfted  by  the  arterial  pulsation.  Abscesses, 
or  serous  cysts,  are  the  most  difficult  to  recognize.  In  the  formation  of 
an  abscess  there  is  a  previous  history  of  inflammation.  An  aneurismal 
tumor  expands  equally  in  all  directions,  while  any  other  tumor  travels 
with  the  arterial  pulse  in  one  direction  only — that  of  least  resistance.  In 
cases  of  great  difficulty  of  diagnosis  it  will  be  justifiable  to  aspirate  the 
tumor  with  the  finest  hypodermic  needle. 

Left  to  nature,  the  progress  of  an  aneurism  is,  with  rare  exceptions, 
to  a  fatal  termination.  The  deposit  of  fibrillated  fibrin  within,  and  the 
inflammatory  new-formed  tissue  without,  may  retard,  but  rarely  arrests, 
the  progi'ess  of  the  disease.  Added  to  the  danger  of  death  from  rupture 
of  the  sac,  or  compression  of  neighboring  organs,  is  that  of  inflammation 
and  sloughing  of  the  tumor  and  its  contents.  The  hope  of  recovery  is  in 
the  gradual  deposition  of  fibrin  within  the  sac,  causing  its  ultimate  occlu- 
sion, or  that  of  the  vessel  or  vessels  immediately  connected  with  it.  The 
danger  of  gangrene  in  the  parts  beyond  the  tumor  is  lessened  with  the 
gradual  establishment  of  the  collateral  circulation,  while  the  sac  and  its 
contents  are  less  apt  to  inflame  than  when  the  occlusion  is  sudden  and 
the  clot  recent. 

The  treatment  of  aneurism  is  constitutional  and  local.  The  constitu- 
tional treatment  is  directed  toward  the  judicious  support  of  the  physical 
powers  of  the  patient,  the  relief  from  pain,  and  the  production  of  a  con- 
dition of  the  blood  favorable  to  a  deposit  of  fibrillated  fibrin  in  the 
tumor. 

The  local  measures  are  directed  to  the  mechanical  control  and  arrest, 
either  gradual  or  immediate,  of  the  circulation  in  the  aneurism,  with  the 
same  end  in  view,  namely,  the  formation  of  fibrin  within  the  sac. 

Constitutional  measures  alone  ofl'er  little  hope  of  a  cure,  and  are  ajapli- 
cable  only  to  cases  where  the  dangers  of  operative  interference  are  suffi- 
cient to  contra-indicate  any  surgical  procedure.  In  this  plan  of  treatment 
rest  in  bed  is  the  first  and  essential  requirement.  In  conjunction  with 
this  there  may  be  administered  certain  remedies  which  diminish  the 
rapidity  of  the  circulation,  or  affect  the  blood-vessels  or  blood  in  such  a 
manner  that  the  gradual  deposit  of  fibrin  in  the  sac  is  produced.  Val- 
salva's method  of  rest  in  bed,  venesection,  and  gradual  starvation,  in 


206 


A  TEXT-BOOK   ON   SURGERY. 


order  to  slacken  the  blood-current  and  thus  cause  coagulation  in  the 
aneurism,  is  now  almost  entirely  abandoned.  Though  heroic,  this  plan 
of  treatment  is  not  without  good  results,  as  will  be  shown  in  the  report 
of  cases  of  special  aneurism  on  a  future  page.  * 

Tafnell  modified  Valsalva's  method  by  omitting  blood-letting  and 
substituting  a  restricted  diet,  with  the  minimum  of  fluids.  Rest  in  the 
recumbent  position  must  be  rigidly  enforced.  Among  the  remedies 
which  have  been  recommended  for  internal  administration,  iodide  of 
potassium,  fluid  extract  of  ergot,  alone  or  with  infusion  of  digitalis,  and 
tincture  of  the  chloride  of  iron,  are  worthy  of  consideration. 

Among  the  many  surgical  procedures  instituted  for  the  relief  of 
aneurism,  those  two  which  deserve  the  first  consideration  are  compression 
and  the  ligature.  In  the  results  achieved  in  their  various  methods  of 
application  all  other  treatment  may  be  practically  excluded. 

Compression  may  be  employed  on  the  cardiac  side  of  an  aneurism, 
close  to  the  tumor,  without  an  intervening  collateral  branch,  or  at  a  dis- 


Antyllus's  method. 


WarJrop's  method.      Anel's  method. 
Fig.  272. 


Hunter's  method.     Brasdor's  method. 


tance  from  the  sac,  with  one  or  more  intervening  branches.  It  may  be 
employed  on  the  distal  side,  with  or  without  intervening  anastomosis,  or 
directly  to  the  surface  and  back  of  the  tumor,  or,  again,  on  both  periph- 
eral and  central  sides,  mth  or  without  direct  compression  of  the  aneurism. 
The  ligature  may  be  applied  on  the  cardiac  side  of  the  tumor,  there 


*  See  "SubclaviaQ  Aneunsni;"  fourteen  cases  by  Valsalva's  method. 


ANEURISM. 


207 


being  one  or  more  branches  given  off  between  the  ligature  and  the  sac 
(Hunter's  method),  or  without  an  intervening  branch  (Anel),  or  on  the 
distal  side  without  (Brasdor),  or  with  (Wardrop)  an  intervening  branch, 
or  close  to  the  tumor  on  both  the  distal  and  cardiac  side,  with  or  without 
extirpation  of  the  tumor  (Antyllus)  (Fig.  272). 

.  When  interrupted  pressure  upon  the  main  trunk,  on  the  cardiac  side 
of  an  aneurism,  is  possible,  it  is  the  iirst  method  of  treatment  to  be 
adopted.  It  can  only  be  contra-indicated  when  the  tumor  is  so  near  to 
the  great  cavities  from  which  the  arteries  emerge  that  there  is  not  suffi- 
cient room  for  its  accomplishment,  or  when,  on  account  of  the  anatomical 
arrangement  of  contiguous  nerves  and  veins,  compression  is  painful  or 
inexpedient,  or  when,  as  will  occur  only  in  exceptional  instances,  rupture 
is  imminent ;  then  the  ligature  is  demanded. 

Compression  may  be  manual  or  instrumental,  and  continuous  or  in- 
terrupted. 

Given  a  popliteal  aneurism,  as  an  illustration,  compression  on  the 
cardiac  side,  with  an  intervening  branch,  may  be  employed  as  fol- 
lows : 

Digital  or  Manual. — The  patient,  being  placed  in  a  position  comfort- 
able to  himself  and  convenient  to  the  operator,  is,  if  the  necessity  de- 
mands, put  under  the  influence  of  an  ojjiate  or  anaesthetic.  Compression 
is  then  made  with  the  piilp  of  the  thumb  laid  upon  the  femoral  artery, 
just  where  it  crosses  the  rim  of  the  pelvis,  until  pulsation  in  the  tumor  is 
diminished  or  arrested.  Additional  force  is  gained  by  pressing  the 
thumb  or  fingers  of  the  opposite  hand  on  the  dorsum  of  the  thumb  first 


employed.  When  fi'om  fatigue  further  compression  is  impossible,  the 
operator  is  relieved  by  the  next  of  the  detail,  and  so  on.  After  a  lapse 
of  from  two  or  three  hours  to  at  times  as  much  as  three  days,  the  tumor 
ceases  to  pulsate,  becomes  firm  and  inelastic,  and  remains  permanently 
occluded. 


208 


A  TEXT-BOOK  ON  SURGERY. 


Mechanical.— A.  method  less  tiresome  to  the  oi)erator,  no  more  annoy- 
ing to  the  patient,  and  almost,  if  not  equally,  as  effective,  is  as  follows : 
One  or  two  sticks  of  hard  wood  about  an  inch  in  diameter,  and  from  four 
to  six  feet  in  length  (smaU-sized  hoop-poles  or  a  crutch  wiU  suffice),  are 
covered  at  one  end  with  an  India-rubber  tip,  or  compress  of  some  soft 
substance.  The  other  end  is  tied  to  the  ceiling  with  a  string  or  to  a  bar 
over  the  bed,  and  allowed  to  descend  until  the  tipped  extremity  rests 
with  the  required  weight  upon  the  vessel  to  be  compressed  (Fig.  273). 
It  may  be  convenient  to  employ  two  poles,  so  that  one  may  press  a  few 
inches  lower  down  than  the  other.  If  one  is  employed,  the  assistant  or 
patient  can  be  dkected  to  change  the  point  of  pressure  at  intervals,  in 

order  to  prevent  pain  or  ex- 
coriation. For  this  same  pur- 
pose the  late  Prof.  Alpheus 
B.  Crosby  successfully  em- 
ployed an  elastic  tube  par- 
tially filled  with  shot  to  give 
it  the  requisite  weight.  The 
tube  was  suspended  above 
the  bed  and  the  pressure 
regulated  by  the  quantity  of 
shot. 

Various  tourniquets,  with 

one,  two,  or  three  compres- 

FiG.  27-t.  sion-pads,    have    been    used 

with  the  same  object  in  view, 

and  with  varying  success.     Among  the  better  of  these  instruments  is  Dr. 

Briddon's  compressor  (Fig.  274). 

Compression  wT.th  the  mechanism  just  described  may  also  be  em- 
ployed on  the  distal  side  of  the  aneurism,  although  with  less  hope  of 
success  than  in  pressure  on  the  cardiac  side,  which  is  among  the  most 
successful  of  the  conservative  methods  at  the  surgeon's  command. 

Direct  pressure  upon  the  aneurismal  tumor  has  been  employed  in  a 
few  instances  with  a  fair  degree  of  success.  Six  cases  of  subclavian 
aneurism  treated  in  this  manner  will  be  given  hereafter,  with  description 
of  the  mechanism. 

Pressure  on  both  the  distal  and  cardiac  sides,  with  or  without  direct 
pressure  on  the  tumor,  has  been  practiced  by  the  employment  of  Es- 
march's  bandage.  The  patient  being  ansesthetized,  the  bandage  is  ap- 
plied, beginning  at  the  extremity,  and  emptying  the  vessels  by  using 
sufiicient  force  in  its  application,  untU  the  lower  border  of  the  tumor  is 
reached.  In  passing  over  the  aneurism,  about  one  half  the  pressure  is 
employed,  it  being  intended  to  leave  a  certain  quantity  of  blood  within 
the  sac.  As  soon  as  the  upper  boundary  is  reached,  the  same  degree  of 
pressure  is  applied  as  below,  and  the  bandage  is  left  on,  or  the  tubing 
may  be  tightened  around  the  limb  above,  and  the  bandage  removed. 
Cures  have  been  effected  within  an  hour  by  this  practice,  while  the  com- 
pression has  been  exercised  for  several  hours  with  negative,  and  in  some 


ANEURISM.  209 

instances  -nitti  fatal,  results.  The  method  is  inferior  to  digital  or  me- 
chanical compression  on  the  cardiac  side  of  the  tumor,  and  is  decidedly 
more  dangerous. 

Esmarch  reports  two  cases  of  femoral  aneurism  in  which  the  bandage 
failed,  while  the  pole  or  stick  compressors  were  subsequently  successful 
in  each  instance. 

In  the  application  of  the  ligature  the  method  of  Hunter  is  generally 
preferable.  The  advantages  of  this  method  over  that  of  Anel  may  be 
emimerated  as  follows  :  The  ligature  is  applied  at  a  distance  from  the 
aneurism  where  the  artery  is  more  apt  to  be  in  a  healthy  condition,  thus 
diminishing  the  danger  of  secondary  hsemoiThage.  The  existence  of  one 
or  more  collateral  branches  between  the  ligature  and  the  tumor  renders 
the  process  of  coagulation  in  the  sac  less  rapid,  and  consequently  less 
liable  to  inflammation  and  sloughing.  The  only  objection  to  this  method 
of  operating  is  the  possibility  of  failure  due  to  too  fi"ee  anastomosis, 
whereby  the  necessary  diminution  of  the  circulation  is  prevented. 

The  method  of  Anel  is  at  this  date  rarely  performed,  except  in  those 
Instances  where,  on  account  of  the  location  of  the  tumor,  other  methods 
are  impossible. 

Deligation  upon  both  sides  of,  and  close  to,  the  tumor  (method  of 
Antyllus)  is  not  a  recognized  practice  excei^t  in  peculiar  cases,  where 
other  and  less  radical  methods  have  failed.  It  is  especially  adapted  to 
cases  of  aneurismal  tumors  which  have  numerous  anastomoses  connecting 
directly  with  the  cavity  of  the  sac,  as  is  not  infrequent  in  popliteal  aneu- 
rism. That  part  of  the  operation  of  Antyllus  which  consisted  in  incision 
of  the  tumor  and  packing  the  sac  is  seldom  considered  necessary,  the 
double  ligature  being  sufiicient. 

The  operations  of  deligation  npon  the  distal  side  of  an  aneurism,  so 
close  to  the  tumor  that  no  collateral  branch  intervenes  (Brasdor),  or  at  a 
point  more  remote  with  one  or  more  collateral  branches  intervening 
(Wardrop),  are  procedures  which  have  been  frequently  employed,  espe- 
cially within  the  last  few  years.  Preference  is  given  to  AYardrop's  oiDera- 
tion  over  that  of  Brasdor,  for  the  same  reasons  advanced  in  favor  of 
Hunter's  operation,  as  compared  to  that  of  Anel  on  the  cardiac  side,  to 
which  it  may  be  likened.  There  is  no  evidence  that  Brasdor  ever  did 
more  than  suggest  the  distal  operation.  Deschamp  was  the  first  to  per- 
form it  (Oct.  6,  1798),  but  without  success.  Wardrop  modified  the  opera- 
tion and  established  it  by  successful  practice  in  1825.*  The  general 
results  of  this  procedure  have  been  such  as  to  encourage  its  repetition, 
although  the  manner  in  which  ?i partial  arrest  of  the  circulation  through 
an  aneurism  by  deligation  on  the  distal  side  of  the  tumor  induces  coagu- 
lation in  the  sac  is  difficult  of  explanation. 

As  has  been  said  iu  the  chapter  on  "  Surgical  Dressings,"  none  but 
animal  ligatures  should  be  applied  to  arteries.  Antiseptic  catgut  of 
the  largest  size  for  the  larger  vessels  will  be  found  most  convenient. 

*  See  article  by  the  author,  "  American  Journal  of  the  Medical  Sciences,"  January,  1881, 
p,  155;  and  "  Prize  Essay  of  the  American  Medical  Association,"  1878,  p.  94. 
14 


210  A  TEXT-BOOK   ON   SURGERY. 

Barwell's*  ox-aorta  ligatures  are  safe  and  eflScient,  as  are  those  made 
from  nerves  and  first  used  upon  the  living  subject  by  myself.  I  have 
used  the  broad  ox-aorta  (Mr.  Barwell's)  ligature  successfully  in  tying  the 
common  carotid  and  the  subclavian  arteries,  and  have  twice  deligated 
the  common  carotid  with  success,  employing  the  sciatic  nerve  of  a  calf ;  f 
but  the  readiness  with  which  catgut  is  obtained,  and  the  ease  and  com- 
parative safety  of  its  application,  especially  with  the  aid  of  antiseptic 
precautions,  have  led  me  to  give  to  it  the  preference. 

Other  methods  of  treatment  of  aneurisms  which  have  almost,  if  not 
entirely,  fallen  into  disuse  are  galvano-puncture,  massage  or  kneading, 
flexion,  the  introduction  qf  horse-hair  or  wire  into  the  sac,  acupuncture, 
and  the  injection  of  a  coagulating  substance  into  the  sac  or  the  tissues 
around  it.  In  my  opinion,  the  circumstances  which  would  justify  any 
of  these  methods  are  so  rare— if,  indeed,  they  ever  exist — that  they 
scarcely  deserve  recognition  in  practical  surgery.  An  exception  may  be 
made  in  the  use  of  wire  or  horse-hair  in  cases  of  large  abdominal  or 
thoracic  aneurisms  where  death  is  imminent  and  the  ligature  impos- 
sible. 

In  galvano-puncture  one  or  more  needles,  connected  with  both  poles 
of  a  galvanic  battery,  are  introduced  into  the  cavity  of  the  sac  on  oppo- 
site side  or  points  of  the  tumor.  They  do  not  touch  within  the  aneurism, 
the  circuit  being  completed  by  the  blood.  A  twenty-four-cell  battery 
may  be  used,  beginning  with  a  few  cells  and  gradually  increasing  the 
strength  of  the  current  until  the  usual  pain  is  felt  at  the  negative  pole, 
or  until  signs  of  coagulation  are  evident.  The  objections  to  this  method 
are  that  the  clot  is  of  rapid  formation,  may  not  be  permanent,  and  may 
inflame  and  suppurate,  causing  death  from  haemorrhage  or  septicsemia. 

Massage  or  kneading  has  been  successfully  pei-formed  in  a  few  in- 
stances. The  aneurism  is  manipulated  with  the  intention  of  detaching 
from  the  sac  enough  of  the  fibrillated  clot  to  plug  up  the  efferent  vessel 
and  thereb^^  practically  tie  the  artery  on  the  distal  side  (Brasdor).  It  is 
a  safer  and  surer  method  than  galvano-puncture,  though  of  doubtful 
propriety  except  in  small  aneurisms  situated  in  the  arms  or  legs.  The 
danger  of  embolism  in  the  cerebral  circulation  is  too  great  to  justify  this 
or  any  similar  procedure  upon  an  aneurism  connected  with  a  vessel  lead- 
ing toward  the  brain. 

Flexion  or  posture  is  practically  a  method  of  direct  compression, 
using  the  normal  tissues  for  a  pad.  It  is  employed  in  popliteal  aneu- 
rism, where  the  knee  is  flexed  and  fastened  so  as  to  compress  and  par- 
tially occlude  the  tumor  between  the  tibia  and  fibula,  and  the  femur. 
It  is  a  justifiable  method  in  rare  instances.  The  same  practice  may  be 
instituted  at  the  elbow,  but  is  impracticable  at  the  axilla  on  account  of 
the  arrangement  of  the  nerves. 

The  introduction  of  watch-spring  wire,  horse-hair,  catgut-coil,  or  any - 
other  foreign  solid  substance  into  the  cavity  of  an  aneurism  will,  as 

*  See  article  by  the  author  in  "  Archives  of  Medicine,"  June,  1882.  G.  P.  Putnam's  Sons, 
New  Yorli.  t  Ibid. 


SPECIAL  ANEURISMS.  211 

above  given,  rarely  be  justifiable  except  as  a  last  resort  in  cases  where 
the  ligature  or  compression  is  impossible.  For  its  execiTtion  a  pointed 
canula  is  usually  employed,  which,  having  been  introduced  into  the  sac, 
the  wire  or  gut  is  pushed  through.  The  quantity  used  varies  from  two 
or  three  feet  up  to  several  yards.  More  of  the  catgut  may  be  introduced 
than  of  the  metal,  and  the  animal  ligature  should  always  be  preferred  if 
this  procedure  is  adopted. 

Acupuncture  is  the  operation  of  introducing  needles  into  the  cavity 
of  the  sac,  and  allowing  them  to  remain  for  several  hours  iintH  coagula- 
tion ensues.  It  is  not  a  scientific  procedure,  and  the  same  must  be  said 
of  the  injection  of  ergot,  the  iron  sohttions,  or  any  coagulating  substance 
into  the  cavity  of  the  tissues  around  an  aneurism. 


Special  Aneueisms. 

Aneurism  of  the  Thoracic  Aorta. — The  ascending  and  transverse 
portions  of  the  arch  are  most  frequently  affected.  If  the  dilatation  is 
fusiform,  both  of  these  segments  are  apt  to  be  involved ;  if  it  is  a  sac- 
culated aneurism,  it  is  usually  confined  to  one  or  the  other  segment. 
Sacculated  aneurism  of  the  ascending  arch  high  up,  or  of  the  transverse 
arch,  usually  involves  the  orifice  of  one  or  more  of  the  great  vessels 
which  originate  here,  although,  as  in  the  specimen  figured  below  (see 
Fig.  275),  not  infrequently  the  mouth  of  the  sac  opens  close  to  these  ves- 
sels, but  does  not  involve  them. 

The  diagnosis  of  aneurism  of  the  arch  is  generally  obscure  until  the 
dilatation  has  advanced  to  such  an  extent  that  pressure-symptoms  are 
evident.  Pain  of  varying  intensity  may  be  present  in  the  earlier  stages 
of  development  of  both  fusiform  and  sacculated  aneurism.  A  symptom 
of  great  diagnostic  value  is  disturbance  of  the  laryngeal  muscles,  due  to 
pressure  upon  the  recurrent  laryngeal  nerve  of  the  left  side.  This  occurs 
in  dilatation  of  the  transverse  or  descending  segment  of  the  arch.  The 
aneurismal  bruit  may  be  recognized  as  soon  as  the  sacculation  is  well 
advanced.  Interference  "R-ith  respiration,  or  deglutition,  or  the  return 
circulation  in  the  veins,  is  among  other  and  important  pressure-symp- 
toms. 

The  appearance  of  a  tumor  with  an  expansile  pulsation  synchronous 
with  the  cardiac  systole,  in  the  upper  thoracic  region,  determines  the 
diagnosis  of  aneurism.  The  differentiation  of  dilatation  of  the  arch,  from 
a  similar  condition  of  the  innominate,  left  carotid,  or  left  subclavian  in 
the  thorax,  is  difficult,  and  at  times  impossible.  A  number  of  errors  in 
aiagnosis  by  comjpetent  and  honest  observers  are  on  record. 

The  following  points  will  aid  in  arriving  at  a  diagnosis  :  The  tumor  in 
aneurism  of  the  ascending  arch  is  usually  first  apj)reciated  to  the  right  of 
the  sternum,  between  the  clavicle  and  the  third  rib.  The  pressure-symp- 
toms do  not  affect  the  voice  imtil  the  tumor  is  recognizable  in  the  right 
side  of  the  root  of  the  neck,  where  it  involves  the  right  recurrent  laryn- 
geal nerve.     Respu-ation  may  be  interfered  with,  or  cough  produced  by 


212  A  TEXT-BOOK   ON  SURGERY. 

compression  of  the  right  bronchus.  This  condition  will  be  recognized  by 
the  hissing  rales  distributed  over  the  area  of  the  right  lung.  Aneurism 
of  the  transverse  arch  is  usually  first  recognized  to  the  left  of  the  sternum 
on  about  the  same  plane  as  for  the  ascending  segment.  Laryngoscopical 
examination  vrill  demonstrate  that  whatever  of  muscular  paresis  exists 
is  confined  to  the  left  vocal  bands.  If  the  tumor  rises  into  the  neck,  its 
appearance  will  have  been  preceded  by  pressure-symptoms  of  longer 
duration  and  greater  severity  than  in  either  innominate,  carotid,  or  sub- 
clavian aneurism. 

Innominate  aneurism  usually  appears  at  the  upper  margin  of  the 
sternum  in  the  space  between  the  two  tendons  of  origin  of  the  right 
sterno-mastoid  muscle,  or  in  the  interclavicular  notch.  The  disturbance 
of  the  circulation  through  this  vessel  so  affected  may  be  recognized  by 
the  difference  in  the  force  and  character  of  the  pulse-wave  in  the  radial 
arteries  of  the  two  arms.  In  aortic  aneurism,  when  the  innominate  is 
not  compressed  by  the  tumor,  the  pulse-wave  will  be  the  same  in  both 
arms.  It  must,  however,  be  borne  in  mind  that  in  sacculated  aneurisms, 
springing,  as  they  not  infrequently  do,  from  the  arch  in  immediate  prox- 
imity to  the  orifice  of  the  innominate,  and  rising  to  the  root  of  the  neck, 
in  front  of  or  behind  this  artery,  a  positive  diagnosis  is  scarcely  possible. 
The  pressure  on  the  innominate  may  retard  or  weaken  the  right  radial 
pulse,  when  this  vessel  is  not  involved,  while  the  aneurismal  bruit  is 
present  in  the  exact  location  of  this  vessel. 

Aneurism  of  the  left  carotid  artery  will  first  appear  at  the  left  sterno- 
clavicular articulation  in  the  line  of  this  vessel.  The  murmur  will  be 
transmitted  toward  the  distribution  of  this  vessel,  and  will  not  be  heard 
in  its  fellow  opposite. 

When  the  left  subclavian  is  involved,  the  swelling  will  usually  appear 
to  the  left  of  the  sterno-mastoid  muscle,  and  the  pulse  in  the  left  radial 
will  differ  from  that  of  the  right.  When  the  descending  aorta  is  the  seat 
of  aneurism,  the  diagnosis  is  still  more  obscure.  The  peculiar  murmur 
is  most  easily  recognized  by  placing  the  stethoscope  to  the  left  of  the 
vertebral  column  in  the  interscapular  space.  The  chief  pressure-symp- 
toms are  those  which  aft'ect  deglutition  and  lift  the  heart  forward. 

The  clinical  Mstory  of  aneurism  of  the  thoracic  aorta  usually  ends  in 
the  death  of  the  individual.  In  addition  to  the  symptoms  given  in  the 
method  of  diagnosis,  the  gradual  expansion  of  the  tumor  leads  to  more 
painful  and  graver  conditions.  Anxiety,  loss  of  sleep,  pain,  and  cough 
usually  prostrate  the  patient ;  erosions  of  the  ribs,  sternum,  clavicles,  and 
vertebrae  occur,  and  sloughing,  septic  absorption,  or  haemorrhage  may 
produce  a  fatal  termination. 

The  medical  treatment  is  rest  in  bed,  and  the  safe  and  judicious  com- 
bination of  Valsalva's  and  Tufnell's  methods  as  given.  The  surgical 
treatment  is  of  the  most  heroic  order,  and  should  not  be  instituted  until 
a  reasonable  trial  of  the  other  methods  has  proved  them  as  inefficient,  as 
death  is  inevitable.  This  treatment  is  the  deligation  of  one  or  more  of 
the  great  vessels  which  are  derived  directly  or  indirectly  from  the  arch — 
i.  e.,  the  distal  operation. 


SPECIAL   ANEURISMS. 


213 


That  this  operation  is  justifiable,  under  certain  conditions,  has  been 
demonstrated.  Among  a  number  of  cases  in  the  statistics  of  this  pro- 
cedure, the  following  are  from  personal  experience  : 

On  the  21st  of  September,  1880,  I  tied  the  right  carotid  and  subclavian 
arteries  simultaneously  for  the  relief  of  an  aneurism  of  the  ascending 
portion  of  the  aorta.*  The  history  of  the  aneurism  dated  back  sixteen 
months.  Having  developed  rapidly,  it  projected  througli  the  right  second 
intercostal  space,  causing  siich  pain  that  the  operation  was  undertaken. 


Fig.  275. — The  author's  case  of  aneurism  of  the  ascending  aorta. 

This  was  the  second  operation  which  had  knowingly  been  undertaken 
for  the  relief  of  aneurism  of  the  ascending  aorta.  The  ligatures  used 
were  of  ox-aorta,  and  were  as  large  as  the  median  nerve  in  an  adult. 
Despite  the  prostrated  condition  of  the  patient,  she  recovered,  the  tumor 
diminished  perceptibly  in  size,  became  more  solid,  and  ker  general  con- 
dition was  much  improved.     One  month  after  the  operation  she  was  dis- 

*  For  a  full  report  of  this,  and  all  the  other  cases  up  to  that  date,  see  paper  by  the  author  in 
"American  Journal  of  the  Medical  Sciences,"  January,  1881. 


214 


A  TEXT-BOOK   ON   SURGERY. 


cliarged  from  the  hospital,  traveled  to  a  neighboring  State,  where  she 
died,  one  year  later,  from  aciite  diarrhoea.  I  secured  an  autopsy,  which 
revealed  an  aneurism  (Figs.  275,  276)  as  large  as  an  orange  springing  from 
the  ascending  aorta,  at  its  junction  with  the  transverse  segment.  The 
orifice  of  the  tumor  was  an  oval,  about  half  an  inch  by  one  inch  in 
extent.  The  tumor  was  solidified  with  permanent  clot  on  its  lateral  and 
posterior  aspects.  On  the  upper  anterior  surface,  which  had  worn  away 
the  sternum  and  second  rib,  the  sac  was  thin,  with  a  recent  clot  which 


6. — Section  through  the  long  diameter  of  the  tumor. 


filled  a  cavity  not  quite  an  inch  in  diameter.  The  tumor  was  practically 
solidified,  and  had  this  patient  not  returned  to  her  dissipated  practices 
(alcoholism),  I  do  not  doubt  that  her  recovery  would  have  been  complete. 
Prof.  H.  B.  Sands  performed  the  same  operation,  in  1866,  for  a  sup- . 
posed  innominate  aneurism.*  The  tumor  diminished  after  the  opera- 
tion, and  visible  pulsation  ceased.  The  patient  died,  thirteen  months 
later,  from  the  pressure  of  the  tumor  which  sprang  from  the  junction  of 

*  See  "  American  Journal  of  the  Medical  Sciences,"  January,  1881. 


SPECIAL  AXEURISirS.  215 

the  ascending  and  transverse  segments,  just  in  front  of  the  innominate. 
C.  F.  Maunder's  patient  died,  on  the  tif th  day,  from  occlusion  of  the  aorta 
by  a  clot  which  projected  from  the  aneurismal  sac.  The  tumor  sprang 
from  transverse  segment,  a  little  to  the  left  of  the  innominate.*  Heath's 
patient  lived  four  years  after  the  double  distal  ligature.  The  aneurism 
diminished  in  size,  and  the  general  condition  was  much  improved.  The 
sac  ultimately  burst,  with  a  fatal  result.  The  tumor  originated  from  the 
ascending  aorta,  f  Mr.  Richard  BarweU  and  Mr.  Lediard  have  also  per- 
formed this  operation  for  aneurism  of  the  arch.  Mr.  BarweU's  patient 
died  fifteen  months  after  the  operation,  dying  from  dissipation  and 
"  general  wearing  out."  The  aneurism  was  completely  fiUed  with  lami- 
nated clot.     Mr.  Lediard's  patient  survived  ten  months.:!; 

Hobart  tied  the  right  subclavian  in  its  first  division,  and  the  right 
common  carotid,  for  a  supjDosed  innominate  aneurism.  Fatal  haemor- 
rhage occurred  fi'om  the  seat  of  ligature  on  the  carotid  on  the  sixteenth 
day.  The  autopsy  showed  a  pyriform  aneurism  originating  from  the 
aorta,  just  to  the  left  of  the  innominate.  The  sac  was  filled  with  a  firm 
coagulam.* 

Thus,  of  seven  cases  of  simultaneous  deligation  of  the  right  carotid 
and  right  subclavian  arteiies,  two  died  on  the  fifth  and  sixteenth  days, 
respectively,  from  the  effect  of  the  operation.  The  remaining  five  recov- 
ered, with  evident  improvement.  A  point  of  great  interest  is  to  notice 
the  effects  of  the  operation  upon  tJie  tumor. 

In  my  case  there  was  no  immediate  change  in  the  aneurism.  Within 
twenty-two  hours  the  diminution  was  evident,  and  by  the  foiirth  day  it 
had  shrunk  from  an  elevation  of  one  inch  aud  a  half  above,  do^vn  almost 
to  the  level  of  the  skin  upon  the  thorax.  In  Sands's  case  "  the  tumor 
diminished  after  the  operation,  and  visible  pulsation  ceased."  There  was 
no  diminution  in  Maunders  case,  but  after  death  the  sac  was  almost  com- 
pletely fiUed  with  recent  clot,  which  had  even  occluded  the  aorta.  In 
Heath's  case  "  the  tumor  gradually  diminished  in  size."  The  symptoms 
so  far  disappeared  in  BarweU's  patient  that  that  surgeon  informed  me, 
"  The  aneurism  is.  judging  from  symptoms,  cured."  In  Lediard's  case  the 
"laryngeal  symptoms  disappeared  ;  the  tumor  had  a  more  consolidated 
feeling."     The  sac  in  Hobart's  case  "  was  fUled  with  firm  coagulum." 

The  evidence  in  these  cases — which  are  all  I  have  been  able  to  collect 
— in  which  the  right  subclavian  and  right  carotid  arteries  were  simultane- 
ously tied  for  aneurism  of  the  arch  of  the  aorta,  involving  the  last  portion 
of  the  ascending  segment,  or  the  first  portion  of  the  transverse  segment, 
or  both,  points  to  the  conclusion  that,  in  sacculated  aneurism  affecting 
the  arterial  limit  just  given,  the  double  distal  ligature  tends  to  produce 
consolidation  of  the  tumor,  and  to  relieve  the  symptoms  of  distress 
caused  by  its  presence.  \ 

*  See  "  American  Journal  of  the  Medical  Sciences,"  Jannary,  1881.  t  Ibid. 

X  Author's  article  on  Distal  Ligature  for  Aneurisms  near  the  Heart,  "American  -JourDal  of 
the  Medical  Sciences,"  January,  1881.  *  Ibid. 

I  See  author's  case  of  deligation  of  the  left  subclavian  and  left  common  carotid  arteries  for 
aneurism  of  the  transverse  portion  of  the  arch,  page  233. 


216  A  TEXT-BOOK   ON  SURGERY. 

In  the  study  of  cases  in  which  one  or  the  other  primitive  carotid  has 
been  tied  for  uncomplicated  aortic  aneurism  1  am  enabled  to  collect  but 
nine  instances.  In  the  limits  of  a  text-book  it  will  be  impossible  to  give  a 
detail  of  such  cases,  however  interesting  to  the  student.  I  refer  him  to  my 
article  on  this  subject  in  the  "American  Journal  of  the  Medical  Sciences," 
January,  1881.  The  operators  were  Montgomery,  T.  Holmes,  Barwell, 
Tillanus,  Rigen,  O'Shaugnessy,  Annandale,  Heath,  and  Bryant.  The  left 
carotid  was  tied  in  six  cases,  and  all  recovered.  Montgomery' s  patient 
died,  four  months  after  operation,  from  purulent  pericarditis.  The  tumor 
had  solidified  and  sloughed.  Holmes's  case  was  much  improved,  and,  in 
answer  to  my  inquiry  concerning  this  case,  in  1880,  five  years  after  the 
operation,  he  writes  that  the  patient  is  still  living,  that  there  is  pulsation 
and  bruit  in  the  thoracic  portion  of  the  aneurism,  but  there  is  no  longer 
any  tumor  perceptible  in  the  neck. 

Barwell's  case  was  greatly  relieved,  dying  four  months  later  of  another 
aifection.  Tillanus's  operation  was  followed  by  recovery  and  diminution 
of  the  tumor,  dying  suddenly  five  months  later  (probably  from  cerebral 
embolism).  The  sac  was  completely  filled  with  coagulnm.  Rigen  tied 
the  carotid,  February  21,  1829.  The  patient  was  relieved,  and  the  tumor 
diminished  considerably  in  volume.  On  May  9th  was  operated  on  for 
strangulated  hernia,  and  died  June  13th,  as  was  sixpposed,  from  asthma. 
The  tumor  was  solidified.  In  Heath's  case  the  relief  for  a  long  period 
was  marked  and  undoubted.  The  patient  lived  nearly  four  years,  dying 
ultimately  of  rupture  of  the  sac. 

O'Shaugnessy  tied  the  right  carotid,  with  fatal  rupture  of  the  aneurism 
into  the  mediastinum  on  the  tenth  day.  Annandale  performed  the  same 
operation  with  immediate  relief  and  success.  Mr.  Bryant's  patient  died 
on  the  tenth  day.  The  right  carotid  was  tied,  with  no  effect  on  the 
aneurism.  The  results  in  these  instances  also  lead  me  to  conclude  that, 
in  sacculated  aneurisms  of  the  aorta,  near  the  origin  of  the  innominate 
and  left  carotid,  deligation  of  one  carotid,  especially  the  left,  is  a  justi- 
fiable procedure  when  the  conservative  method  of  rest  and  restricted  diet 
has  failed. 

Aneurism  of  the  thoracic  aorta  beyond  the  transverse  segment  is  not 
amenable  to  surgical  treatment. 

Aneurism  of  the  Innominate  Artery. — The  symptoms  of  this  for- 
midable lesion  have  been  given  on  a  preceding  page.  It  is  frequent- 
ly complicated  with  aneurismal  dilatation  of  the  aorta,  or  of  the 
two  vessels  into  which  it  usually  bifurcates.  It  will  be  interesting 
to  study  the  results  of  ojperative  procedures  under  the  following  sub- 
divisions : 

1.  Innominate  Aneurism.  2.  Aortic  innominate  Aneurism. — For  in- 
nominate aneurism,  (a)  the  double  simultaneous  distal  ligature  (carotid 
and  third  division  of  the  siibclavian) ;  (6)  the  double  non-simultaneous 
distal  operation  ;  (c)  distal  deligation  of  the  carotid  artery  alone ;  (d) 
distal  deligation  of  the  subclavian  artery  alone. 

Simultaneous  Deligation  of  the  Right  Common  Carotid  and  tlie 
Right  Subclavian  Artery  {Third  Division)  for  the  Belief  of  Innominate 


SPECIAL  ANEURISMS.  217 

Aneurism.  * — Prof.  J.  L.  Little  performed  this  operation  in  1877.  The 
patient  recovered,  was  much  improved,  and  died  from  pleuritis,  not  asso- 
ciated with  the  aneurism,  three  years  later.  The  carotid  and  subclavian 
were  slightly  involved.  Durham's  patient  died  on  the  sixth  day,  as  was 
reported,  from  "shock."  The  possibility  of  cerebral  embolism  is  worthy 
of  consideration  in  exjolaining  the  sudden  death  of  this  patient.  M'Car- 
thy's  case  died,  on  the  fifteenth  day,  from  hfemorrhage  on  the  proximal 
side  of  the  subclavian  ligature.  Prof.  Eliot's  patient  died,  on  the  twenty- 
sixth  day,  from  haemorrhage  from  the  sac.  Prof.  L.  A.  Stimson's  j^atient 
recovered,  with  marked  improvement  and  consolidation  of  the  aneurism. 
The  tumor  became  very  much  smaller,  and  the  symptoms  were  relieved. 
Death  occurred,  twenty-one  months  after  the  operation,  from  phthisis. 
The  sac  was  filled  with  firm.  clot.  In  the  case  operated  upon  by  Prof.  R. 
F.  Weir,  death  resulted,  from  rupture  of  the  sac,  on  the  fifteenth  day. 
Rossi's  patient  died  on  the  sixth  day,  most  probably  from  cerebral  anae- 
mia, since,  at  the  necropsy,  the  left  vertebral  was  the  only  pervious 
artery  leading  to  the  brain.  Ensor's  case  ended  in  death,  from  rupture 
of  the  sac,  on  the  sixty-fifth  day.  Barwell  operated,  with  recovery  and 
marked  improvement.  King's  patient  died,  from  haemorrhage  from  the 
aneurism  near  the  carotid  ligature,  on  the  one  hundred  and  eleventh  day. 
Gerster's  case  recovered,  with  gradual  improvement. f 

Of  these  eleven  cases,  recovery,  with  a  cure  more  or  less  perfect,  took 
place  in  four,  while  death  occurred  in  seven.  It  is  very  probable  that,  if 
in  some  of  these  fatal  cases  the  operation  had  been  performed  earlier, 
the  rate  of  mortality  would  have  been  lower. 

The  double  distal  operation,  with  varying  intervals  between  the  deli- 
gation  of  the  carotid  and  the  subclavian  arteries,  has  been  performed  in 
the  following  instances  :  Prof.  A.  B.  Mott  tied  the  subclavian  artery  in  a 
patient  who  had  had  the  right  carotid  deligated  one  year  previously.  The 
patient  died,  three  years  after  the  last  operation,  from  phthisis.  The 
aneurism  was  cured.  In  Heath's  case  the  carotid  was  first  tied,  with  tem- 
porary amelioration  of  symptoms.  Two  years  later  the  subclavian  was 
operaied  upon.  The  aneurismal  bruit  disappeared,  and  the  urgent  symp- 
toms disappeared.  Four  months  later  the  patient  died  from  traumatic 
pleuritis,  caused  by  a  fall  while  drunk.  The  tumor  was  consolidated. 
In  Wickham's  case  the  interval  was  two  months  and  nine  days.  Imme- 
diate and  temporary  relief  followed  both  operations.  Death  ensued  from 
rupture  of  the  sac  on  the  forty-fourth  day.  Malgaigne's  patient  was  not 
materially  benefited  by  the  first  operation.  Three  months  later  the 
subclavian  was  tied,  followed  by  death,  from  rupture  of  the  sac,  on  the 
twenty -first  day. 

A  glance  at  these  cases,  and  a  careful  study  of  their  more  complete 
histories,  can  not  but  impress  one  with  the  gravity  of  the  surgical  pro- 
cedure under  consideration.  The  postural,  dietetic,  and  medicinal 
method  should  be  thoroughly  tried  in  all  cases  where  the  disease  has  not 

*  For  more  complete  detiiils,  see  preceding  reference. 
t  "  German  Hospital  Records,"  1883-'84:,  New  York  city. 


218  A  TEXT-BOOK   ON   SURGERY. 

progressed  so  far  that  deatli  is  imminent  from  pressure,  or  the  suffering 
so  intense  that  life  becomes  intolerable.  Under  these  last  conditions  the 
operation  is  justifiable.  If  the  conservative  method,  after  a  courageous 
and  faithful  trial,  does  not  arrest  the  disease,  then  again  the  operation 
is  demanded.  There  is  little  choice  between  the  simultaneous  deligation 
and  the  operation  with  an  interval.  The  carotid  should  always  be  first 
tied,  to  prevent  the  danger  of  cerebral  embolism. 

Innominate  Aneurism  treated  by  Deligation  of  the  Carotid,  or  the 
Subclaman.  {The  Single  Distal  Operation.) — The  records  of  surgical 
literature  contain  fourteen  instances  in  which,  for  the  relief  of  aneurism 
involving  the  innominate  artery  alone,  the  distal  ligature  was  applied  to 
the  right  carotid. 

In  Button's  case  death  occurred,  on  the  seventh  day,  from  rupture  of 
the  sac  ;  Neumeister's  on  the  fifth  day,  from  cerebral  complications.  One 
of  Valentine  Mott's  patients  died,  from  haemorrhage  from  the  carotid,  on 
the  twentieth  day.  In  Porta's  case,  which  ended  fatally  in  forty  hours, 
the  sac  was  found  to  have  involved  the  origins  of  the  right  carotid  and 
subclavian  arteries.  A  similar  condition  was  observed  in  the  case  oper- 
ated uj)on  by  Vilardebo,  which  terminated  fatally  on  the  twenty-first  day. 
Fergusson's  patient  died  on  the  seventh  day.  The  autopsy  showed  that 
the  origin  of  the  subclavian  was  also  involved.  The  case  by  Butcher 
ended  in  death  on  the  fourth  day.  The  innominate  was  the  seat  of  a 
fusiform  dilatation,  while  the  sacculated  aneurism  was  found  to  exist  in 
the  third  portion  of  the  subclavian  artery.  Holmes  reports  a  case  by 
Ordile,  of  Naples,  which  also  proved  fatal. 

A  case  by  Scott  was  temporarily  benefited,  but  did  not  long  survive, 
dying  from  rupture  of  the  sac.  Nussbaum's  patient  was  not  benefited, 
and  died  from  the  progress  of  the  disease.  The  case  of  Morrison,  in 
which  the  anexirism  involved  the  origin  of  the  carotid,  recovered,  with 
improvement,  but  died  suddenly  one  year  and  eight  months  later,  after 
prolonged  exertion.  A  second  case  by  V.  Mott  recovered,  with  marked 
temporary  improvement,  but  death  ensued  from  pressure  of  the  consoli- 
dated tumor  on  the  trachea.  Pirogoff's  patient  recovered,  improved. 
The  history  of  this  case  ceases  after  two  months  and  a  half. 

In  one  single  instance  (Evans's)  a  cure  was  efl:ected,  and  this  after 
suppuration  occurred  in  the  sac,  which  discharged  twenty-four  ounces 
of  pus. 

Of  the  fourteen  cases,  eight  ended  fatally.  Seven  of  these  died  between 
the  second  and  twenty-first  day,  and  in  one  of  these  it  is  evident  that 
death  was  caused  by  the  consolidation  of  the  aneurism. 

Another  surgical  procedure  for  the  relief  of  innominate  aneurism, 
which  has  received  the  sanction  of  eminent  practitioners,  is  that  of  single 
deligation  of  the  subclavian  artery  in  its  third  division.  The  operators 
are  Wardrop,  Broca,  and  Thomas  Bryant.  Each  case  recovered,  with 
marked  improvement.  Wardrop's  patient  lived  two  years,  and  died 
partly  from  the  effect  of  pressure  of  the  aneurism  and  partly  from  genei-al 
systemic  failure.  The  tumor  was  firmly  solidified,  with  the  exception  of 
a  small  central  channel  which  led  into  the  carotid.     Broca's  case  died, 


SPECIAL  ANEURISMS.  219 

from  pulmonary  gangrene,  five  montts  later.  ■  Consolidation  was  also 
almost  complete  in  this  case.  Bryant's  patient  was  living  one  year  after 
the  operation,  and  there  was  evidence  of  solidification  in  the  tumor. 

"While  it  is  scarcely  possible  to  base  a  definite  opinion  upon  a  study 
of  such  a  limited  number  of  cases,  the  evidence  seems  to  be  in  favor  of 
the  operation  of  tying  the  subclavian  in  preference  to  the  carotid  for 
innominate  aneurism.  It  would  be  natural  to  infer  that  the  danger  from 
cerebral  embolism  would  be  great  after  such  a  procedure,  yet  it  evidently 
did  not  occur  in  either  of  these  instances. 

Deligation  of  the  right  carotid  alone  is  demonstrated  to  be  so  dangerous 
an  operation  that  I  should  hesitate  to  perform  it  until  all  other  expedients 
had  failed. 

In  aneurism  involving  both  the  innominate  and  the  aortic  arch,  the 
double  distal  ojjeration  is  recorded  in  eight  instances.  In  the  following 
cases  the  two  vessels  were  tied  at  the  same  operation,  excepting  one  in 
which  there  was  an  interval  of  only  twenty -four  hours.  Mr.  Barwell,  in 
one  instance,  with  a  recovery  and  very  great  improvement.  The  patient 
died,  nineteen  months  later,  from  bronchitis.  The  tumor  was  firmly  con- 
solidated. The  same  surgeon,  in  a  second  case  (with  an  interval  of 
twenty-four  hours),  with  recovery  and  great  imjarovement.  Death  from 
broncho-pneumonia  three  months  later.  The  tumor,  as  large  as  a  tennis- 
ball,  was  solid,  excejating  a  central  globular  cavity  one  inch  in  diameter. 
The  same  surgeon,  in  a  third  case,  which  ended  fatally,  from  asphyxia, 
in  thirty  hours.  Mr.  Holmes's  patient  died  from  exhaustion  two  months 
after  oiaeration.  The  sac  was  full  of  recent  clot.  Mr.  Lane's  case  termi- 
nated fatally  within  three  months,  from  rupture  of  the  sac.  The  j^atient 
operated  upon  by  Mr.  Hodges  died,  mth  symptoms  of  broncho-pneu- 
monia, on  the  twelfth  day.  There  was  no  sacculated  aneurism,  but  an 
extensive  fusiform  dilatation  of  the  innominate  and  aorta.  Ransohoff's 
case  ended  fatally,  from  asphyxia,  in  seven  days.  In  one  instance  Mr. 
Bickersteth  operated,  with  an  interval  of  forty-nine  days,  but  without 
benefit,  as  the  patient  died  from  the  progress  of  the  disease  in  three 
months. 

The  results  in  these  cases  do  not  encourage  a  repetition  of  this  opera- 
tion in  well-marked  instances  of  aorto-innominate  aneurism.  The  con- 
servative methods  offer  the  best  hope  of  palliation. 

The  deligation  of  one  of  the  primitive  carotids  has  been  performed  in 
six  instances  for  the  relief  of  aneurism  involving  the  innominate,  compli- 
cated with  dilatation  of  the  aorta  or  the  first  portion  of  the  right  sub- 
clavian or  carotid.  Pirogoff  tied  the  left  carotid  in  two  cases.  One  died 
within  a  week,  from  hemiplegia  and  coma  ;  the  sac  was  completely  filled 
with  clot.  The  other  recovered,  and  was  improved  up  to  two  months, 
when  the  history  ceases.  In  the  remaining  four  cases  the  right  carotid 
was  tied.  The  operation  by  Hewson  tenninated  fatally  on  the  tenth  day, 
from  asphyxia,  due  to  pressure  from  the  consolidated  tumor.  The  two 
terminal  branches  of  the  innominate  were  also  involved.  Campbell's 
patient  suffered  a  like  fate,  from  the  same  cause,  while  Key's  was  also 
fatal  in  four  hours,  from  coma.      Hutchison's  died  on  the  forty-first 


220  A  TEXT-BOOK   ON  SURGERY. 

day,  from  asphyxia,  due  to  pressure  of  the  enlarged  and  consolidated 
aneurism. 

Thus,  in  six  cases,  five  died  within  a  few  days  after  the  operation,  and 
three  of  these  seem  to  have  ended  fatally  from  consolidation  of  the  aneu- 
rism, the  very  object  for  which  it  was  performed. 

Aneurism  of  the  Common  Carotid  Artery. — Aneurism  of  the  carotid 
may  occur  in  any  part  of  the  course  of  this  vessel,  being  in  rare  instances 
intra- thoracic  (when  the  left  trunk  is  involved). 

The  diagnosis  of  aneurism  of  the  left  carotid,  low  down,  depends  upon 
the  presence  of  the  aneurismal  bruit  at  the  spot  of  the  tumor,  this  mur- 
mur being  carried  along  in  the  distribution  of  the  artery.  Pressure- 
symptoms  are  referable  to  laryngeal  interference  from  compression  upon 
the  pneumogastric  ;  or  distention  of  the  left  internal  jugular,  and  in  rare 
instances  the  left  subclavian  vein.  The  presence  of  the  swelling  is  usu- 
ally first  recognized  in  the  space  between  the  two  tendons  of  origin  of 
the  left  sterno-mastoid  muscle.  Aneurism  of  the  right  carotid,  within 
the  first  inch  of  its  course,  gives  rise  to  the  ordinary  symptoms  of  this 
lesion,  just  beneath  the  sterno-mastoid  muscle,  at  and  immediately  above 
its  clavicular  origin. 

Aneurism  of  the  vertebral  artery,  in  its  lower  portion,  may  be  differ- 
entiated from  that  of  the  carotid  by  compression  of  this  latter  vessel  high 
up.  If  the  thumb  be  placed  over  the  carotid,  at  its  bifurcation,  and 
pressed  firmly  and  directly  backward  against  the  vertebral  column,  such 
compression  will  not  affect  the  circulation  in  the  sac  of  a  vertebral  aneu- 
rism, while  if  involving  the  carotid  it  would  be  visibly  affected.  Then, 
again,  vertebral  aneurism  is,  in  nearly  every  instance,  of  traiimatic  origin, 
and  the  traumatism  is  usually  a  stab  wound,  while  aneurism  of  the  carotid 
is  almost  always  idiopathic. 

In  the  differential  diagnosis  of  these  two  lesions  higher  in  the  neck, 
the  same  method  is  applicable.  It  should  not  be  forgotten,  in  the  effort 
to  form  a  diagnosis,  that  careless  manipulation  of  a  cervical  aneurism  is 
not  allowable,  on  account  of  the  danger  of  detaching  a  clot,  which  may 
pass  up  into  the  brain.  If  the  tumor  involve  the  carotid  or  its  branches, 
compression  of  the  primitive  trunk,  low  down,  will  arrest  the  pulsation 
in  the  sac.  This  is  best  accomplished  by  relaxing  the  sterno-mastoid 
muscle  of  that  side,  and  grasping  the  vessel  between  the  thumb  and 
finger  carried  behind  the  muscle.  On  account  of  the  deep  seat  of  the 
vertebral  artery  its  compression  by  this  manoeuvre  is  impossible.  This 
last  vessel  may  be  compressed  by  placing  the  thumb  one  inch  directly 
below  the  transverse  process  of  the  sixth  cervical  vertebra,  and  pressing 
backward.  Above  this  point  it  is  impossible,  since  the  vessel  runs  into 
the  vertebral  foramina. 

The  treatment  of  carotid  aneurism  is  surgical  and  palliative.  The  last 
method  refers  to  the  postural,  dietetic,  and  medicinal  treatment  of  aneu- 
risms in  general.  The  only  surgical  procedure  which  should  be  recom- 
mended is  the  ligature.  While  it  is  true  that  some  cases  are  recorded  as 
cured  by  digital  compression,  I  can  not  but  consider  this  method  as  dan- 
gerous, for  the  reason  that,  in  the  process  of  consolidation  where  the  cir- 


SPECIAL  ANEURISMS.  221 

cnlation  is  only  temporarily  inteiTupted,  cerebral  embolism  may  occur. 
The  animal  ligature,  with  antiseptic  cleanliness,  offers  the  safest  means  at 
our  disposal.  The  operation  varies  Avith  the  seat  of  the  tumor.  It  may  be 
divided  into  deligation  upon  the  distal  and  cardiac  side  of  the  anenrism. 

The  distal  ligature  has  been  applied  in  seven  recorded  instances — five 
on  the  right  and  two  on  the  left  carotid.  Two  deaths  occurred  from 
haemorrhage  ;  one  fi-om  the  distal  side  of  the  (silk)  ligature  on  the  sixty- 
first  day,  the  second  case  fi-om  ruptnre  of  the  anenrism  on  the  sixty- 
seventh  day.  A  third  case  recovered,  but  the  progress  of  the  disease 
was  not  arrested,  and  death  followed  the  ruptiu'e  of  the  sac  on  the  ninety- 
first  day.  The  remaining  four  cases  were  either  much  improved  or  cured. 
The  use  of  the  catgut  ligature  would  probably  have  saved  the  patient 
operated  upon  by  Lambert,  in  which  silk  was  used,  causing  death  fi'om 
haemorrhage  on  the  sixty-first  day. 

Deligation  upon  the  cardiac  side  is  always  preferable  when  a  sufficient 
extent  of  sound  artery  can  be  secured  around  which  to  apply  the  ligature. 
In  my  "Essays  on  the  Surgery  and  Anatomy  of  the  Great  Vessels  of  the 
Neck "  I  have  recorded  106  cases  in  which  the  artery  was  tied  on  the 
cardiac  side  of  the  aneurism  ;  69  recovered  ;  rate  of  mortality,  35  per  cent. 
For  aneurism  of  the  external  carotid  or  its  branches,  17  recoveries  and  5 
deaths.  Of  the  17  recoveries  16  were  cured.  For  aneiirism  involving  the 
common  carotid  alone,  the  death-rate  was  44  per  cent.  When  the  aneu- 
rism involves  the  common,  external,  and  internal  carotids,  the  ligature 
should  be  apjDlied  to  the  common  trunk,  on  the  cardiac  side,  while  the 
distal  ligature  may  be  applied  to  the  external  trunk,  at  the  same  time 
securing  the  larger  branches  derived  from  this  vessel  between  the  ligature 
and  the  bifurcation.  By  this  operation  the  circulation  through  the 
tumor,  and  in  the  direction  of  the  brain,  is  practically  arrested. 

Aneurism  of  the  external  carotid  demands  the  deligation  of  this  vessel 
and  no  other,  when  by  a  careful  dissection  it  is  discovered  that  there  is  a 
half  or  three  quarters  of  an  inch  of  this  trunk  between  the  bifurcation  and 
the  sac.  In  two  instances  I  have  placed  the  ligature  around  the  external 
carotid  exactly  at  the  crotch  of  bifurcation,  tying  also  the  superior  thy- 
roid branch.  Both  cases  recovered  without  accident.  In  the  event  that 
this  method  is  impracticable,  the  common  trunk  must  be  tied. 

Aneurism  of  the  internal  carotid,  in  the  neck,  should  be  treated  by  the 
deligation  of  this  vessel,  between  the  sac  and  the  common  trunk,  if  possi- 
ble. When  a  sufficient  surface  of  healthy  artery  can  not  be  obtained, 
the  common  and  external  carotids  should  be  tied,  together  with  all 
branches  derived  from  the  external,  on  the  cardiac  side  of  the  ligature. 
I  performed  this  operation  ia  one  instance,  resulting  in  the  rapid  and 
permanent  cure  of  a  large  extra-cranial  aneurism  of  the  internal  carotid. 
The  common  trunk  was  first  tied  with  a  nerve  ligature,  after  which  cat- 
gut was  applied  to  the  superior  thyroid,  and  external  carotid,  just  above 
its  origin. 

Aneurism  of  the  internal  carotid  may  occur  in  the  cavernous  or  cere- 
bral portions  of  this  vessel.  In  the  petrous  canal  dilatation  is  practically 
impossible.     Not  infrequently  an  arterio-cavernous  aneurism  occurs  from 


222  A  TEXT-BOOK  ON   SURGERY. 

the  giving  way  of  the  septum  between  these  two  vessels.  The  cause  may 
be  traumatic,  as  in  fractiare  at  the  base  of  the  skull,  or  the  communica- 
tion may  be  established  without  appreciable  cause. 

The  symptoms  of  aneurismal  dilatation  here  are  of  two  kinds  :  those 
referable  to  pressure  upon  the  brain  and  nerves,  and  those  due  to  inter- 
ference with  the  return  venous  current  through  the  ophthalmic  vein.  If 
the  arterio-venous  communication  has  occurred,  exophthalmus  is  marked, 
and  the  eyeball  is  projected  forward  with  each  arterial  pulse.  Singing 
in  the  ears,  dizziness,  with  varying  loss  of  function  due  to  pressure,  are 
other  symptoms  of  this  condition. 

The  ophthalmic  artery  may  be  the  seat  of  aneurism,  within  the  cranial 
cavity  or  in  the  orbit.  True  sacculated  intra-orbital  aneurism  of  this 
artery  is  extremely  rare,  only  two  cases  being  recorded,  *  although  pul- 
sating tumors,  as  arterio-venous  aneurisms,  angeiomata,  cirsoid  arterial 
tumors,  etc.,  are  not  infrequent  in  this  locality.  The  chief  point  in  the 
diagnosis,  and  the  one  which  has  an  important  bearing  in  treatment,  is 
compression  of  the  carotid.  If  pulsation  ceases,  and  the  other  symptoms 
disappear,  the  indication  is  direct  that  the  ligature  should  be  applied  to 
this  vessel.  The  common  trunk  should  be  tied,  in  order  to  cut  off  the 
free  communication  between  the  branches  of  the  external  carotid  and  the 
ophthalmic  in  the  orbit.  In  my  Essays  are  given  tifty-two  instances  in 
which  this  operation-was  done  for  pulsating  non-malignant  tumors  of  the 
orbit,  with  a  death-rate  of  11^  per  cent.f  About  75  per  cent  of  recoveries 
after  this  operation  result  in  cures.  In  severe  cases  extiri)ation  may  be 
necessitated. 

Aneurism  of  any  branch  or  branches  of  the  external  carotid  should  be 
treated  by  comj)ression  on  the  cardiac  side,  when  this  is  practicable,  or 
by  the  ligature  of  the  trunk  involved,  or  the  external  trunk. 

Aneurism  of  the  Subclavian  Arteries. — The  subclavian  arteries  may 
be  affected  in  any  portion  of  their  extent,  although,  on  account  of  the 
pressure  exercised  by  the  two  scaleni  muscles,  between  which  their  second 
portion  lies,  this  division  is  less  frequently  involved  in  aneurismal  dilata- 
tion. The  seat  of  this  disease  is  by  preference  in  the  third  portion,  the 
first  division  being  next  in  order.  Exposure  to  violence  or  muscular  effort 
undoubtedly  has  much  to  do  with  the  development  of  subclavian  aneurism, 
since  males  are  very  much  more  frequently  affected  than  females,  while 
the  tumor  is  found  on  the  right  side,  in  the  great  majority  of  cases. 

The  first  portion  of  the  right  subclavian  is  not  infrequently  involved 
in  the  progress  of  an  innominate  aneurism.  Upon  the  left  side  aneurism 
of  the  thoracic  portion  of  this  vessel  is  rare. 

Subclavian  aneurism,  as  it  usually  develops,  is  first  recognized  as  a 
pulsating  tumor,  felt  rather  than  seen  behind  the  clavicle,  and  to  the 
outer  side,  or  behind  the  sterno-mastoid  muscle.  It  may  be  mistaken  for 
a  glandular  or  other  tumor  of  the  softer  tissues.     The  symptoms  which 

*  Prof.  Sattler's  classical  paper  in  Graefe  and  Saeinisch'a  "  Handbucli  d<»v  gesamrater 
Augenheilkunde,"  Leipsic,  1880. 

t  "Prize  Essays  of  the  American  Medical  Association,  1878,"  William  Wood  &  Co.,  New 
York. 


SPECIAL   AXEFRISMS. 


223 


have  been  already  detailed  will  serve  as  a  guide  to  i^roper  differentiation. 
Ditficnlty  may  arise,  even  after  the  aneurismal  character  of  the  swelling 
has  been  recognized,  in  determining  fi'om  what  vessel  the  tumor  si^rings. 
As  has  been  said,  the  progi'ess  of  aortic  anenrism  gives  rise  to  pulsation 
and  pressure  symptoms,  located  in  the  thorax  for  a  considerable  period 
prior  to  the  approach  or  appearance  of  the  tumor  at  the  root  of  the  neck. 
In  fact,  aneurism  of  the  aorta,  in  many  instances,  produces  death  before 
it  attains  such  magnitude.  On  the  right  side,  this  knowledge  will  aid 
materially  in  recognizing  the  seat  of  the  lesion,  and.  fortunately,  aneu- 
rism of  the  arch  and  subclavian  occurs  most  often  on  this  side  of  the 
body.  The  differentiation  of  aneurism  of  the  thoracic  portion  of  the  left 
artery,  from  the  same  lesion  of  the  arch,  near  the  origin  of  the  subclavian, 
is  somewhat  more  difhcult.  "When  the  tumor  involves  the  subclavian  its 
appearance  in  the  neck  is  more  rapid  than  in  aortic  aneurism,  while  in- 
terference vrith  the  return  circiilation  in  the  arm,  which  may  ajDpear  early 
in  the  history  of  subclavian  aneurism,  is  rare  when  the  aorta  is  the  seat 
of  this  lesion.  Again,  in  aneurism  of  the  second  or  third  portion  of  the 
arch,  which  does  not  involve  the  subclavian,  the  pulse-wave  in  the  left 
radial  will  be  of  equal  force  and  synchronous  with  that  of  the  right  side. 

The  ti'eatment  of  subclavian  aneurism  is  a  subject  of  great  importance, 
and  one  which,  from  a  study  of  a  number  of  cases,  has  led  to  great  diver- 
sity of  opinion  and  practice. 

The  methods  may  be  divided  into  the  surgical ;  the  postural,  medical, 
and  dietetic  ;  and  the  palliative  or  expectant.  The  employment  of  any 
of  these  means  will,  again,  be  in  great  part  determined  by  the  portion  of 
the  artery  involved  in  the  disease.  The  surgical  treatment  comprises  the 
ligature  on  the  cardiac  or  distal  side  ;  compression  on  the  distal  side,  or 
applied  directly  to  the  sac  ;  and  massage. 

The  innominate  artery  has  been  tied  on  account  of  subclavian  aneu- 
rism seventeen  times  with  sixteen  deaths. 

The  operators  and  results  were  as  follows :  V.  Mott,  died  twenty-sixth 
day,  haemorrhage  fi'om  distal  side.  Grraef  e,  died  sixty-seventh  day,  haemor- 
rhage from  distal  side  of  ligature.  ISTorman,  died  thu'd  day,  hsemorrhage. 
Arendt,  eighth  day,  pneumonia.  Hall,  fifth  clay,  exhaustion  and  we/zesec- 
tion.  Bland,  eighteenth  day,  haemorrhage  from  distal  side  of  ligature. 
Lizars,  twenty-second  day,  haemorrhage  from  distal  side.  Gore,  seven- 
teenth day,  haemorrhage  from  cardiac  side  of  ligature.  Cooper,  eighth  day. 
Cooper,  thirty-fourth  day,  haemorrhage.  Pirogoff,  two  days,  pneumonia. 
A.  B.  ilott,  twenty-third  day,  haemorrhage,  sac  burst  into  pleura.  Bick- 
ersteth,  sixth  day,  haemorrhage  from  distal  side  of  ligature.  Thomson, 
forty-second  day,  haemorrhage  from  distal  side  of  ligature.  Smyth,  recov- 
ered, after  ligature  of  innominate  and  carotid  at  first  operation,  and  the 
vertebral  fifty-four  days  later,  to  arrest  violent  bleeding.  This  patient 
died,  ten  years  later,  from  haemorrhage  from  the  sac  of  the  old  aneurism. 
Thomson,  died  forty-second  day,  exhaustion  from  repeated  haemorrhage 
from  distal  side  of  ligature.  Bull,  thirty-third  day,  haemorrhage  from 
proximal  side  of  ligature  on  thirtieth  and  thirty-third  days  ;  right  carotid 
and  vertebral  also  tied  at  same  time  with  the  innominate. 


224  A  TEXT-BOOK   ON  SURGEKY. 

The  subclaman  artery  has  been  tied  in  its  first  surgical  division  for 
the  relief  of  aneurism  involving  this  vessel,  or  its  third  portion,  conjointly 
with  the  first  part  of  the  axillary  (subclavio-axillary),  in  the  following 
instances :  CoUes,  death  on  fourth  day,  from  haemorrhage  at  seat  of  liga- 
tnre.  V.  Mott,  death  on  eighteenth  day,  heemorrhage.  Bayer,  death 
in  twenty-four  hours,  from  bursting  of  sac.  Hayden,  death  on  twelfth 
day,  from  haemorrhage  at  seat  of  ligature.  O'Reilly,  death  on  thirteenth 
day,  heemorrhage.  Partridge,  death  on  fourth  day,  pericarditis,  pleuritis, 
pyaemia.  Liston,  death  on  thirty-sixth  day,  haemorrhage  from  distal  side. 
Rodgers,  death  on  fifteenth  day,  haemorrhage  from  distal  side  of  ligature. 
Auvert,  death  on  eleventh  day,  haemorrhage,  distal  side.  Auvert,  death 
on  twenty-second  day,  haemorrhage  from  distal  side.  Liston,  death  on 
thirteenth  day,  haemorrhage  (right  carotid  tied  at  same  time).  Parker, 
death  on  forty-second  day,  haemorrhage  from  distal  side  of  ligatixre  (right 
carotid  tied  at  same  operation).  Of  these  twelve  cases  all  died  soon  after 
the  ligature.     Only  in  one  case  (Rodgers)  was  the  left  subclavian  tied. 

For  subclavian  or  subclavio-axillary  aneurism  the  ligature  has  been 
applied  in  the  second  portion  in  four  cases.  Liston,  death  on  fourteenth 
day,  haemorrhage  at  seat  of  ligature.  Nichols,  recovered,  cured.  Au- 
chincloss,  death  on  third  day,  from  cerebral  complications.  Warren, 
recovered,  cured.  Gay,  death  on  ninth  day,  bronchitis  and  pneumonia. 
Giving  four  cases,  with  two  deaths  and  two  cures. 

Deligation  of  the  subclavian  artery,  in  its  third  portion,  for  subclavio- 
axillary  or  axillary  aneurism,  has  been  performed  one  hundred  and  thir- 
teen times,  with  forty-seven  deaths.*  Naturally  the  mortality  is  greater 
in  proportion  to  the  proximity  of  the  aneurism  to  the  heart  and  to  the 
seat  of  the  ligature.  Thus,  in  thirty-four  of  these  cases  the  disease  in- 
volved the  third  portion  of  the  subclavian  or  the  axillary,  or  both  (prop- 
erly named  subclavio-axillary  aneurism).  As  a  result  of  the  operation 
exactly  one  half  perished.  Of  the  seventeen  recoveries,  thirteen  are  re- 
ported cured. 

For  aneurism  of  the  axillary  projser  I  have  the  histories  of  seventy- 
nine  cases  in  which  the  ligature  has  been  applied  to  the  third  portion  of 
the  subclavian,  with  thirty  deaths,  forty-nine  recoveries,  and  forty-six  of 
these  reported  as  cured.  In  seven  of  the  fatal  cases  the  aneurism  was 
traumatic,  and  resulted  from  gunshot  wounds  (six  in  military,  one  in 
civil  practice). 

The  value  of  the  expectant  plan  may  be  estimated  in  the  following 
cases : 

Synopsis  of  22  Cases  of  Subclavian  Aneueism  in  which  "no 
Treatment"  was  undertaken. 

18  deaths,  ^  spontaneous  cures. 

Eighteen  fatal  cases.  Dates  of  death  after  tumor  was  noticed  (and 
when  surgical  interference  might  have  been  undertaken). 

*  Author's  Essays,  already  cited. 


SPECIAL  ANEURISMS. 


225 


1  case.  Aneurism  had  existed  for  "  some  time."  Died  twelve  weeks  after  admis- 
sion to  hospital. 

1  case.     Xot  known  how  long  aneurism  had  existed. 

1  case.  Lived  "  some  months."  Died  of  exhaustion  and  supjDuration  caused  by 
pressure  of  sac. 

1  case.     Died  of  rupture  of  sac  twenty-four  years  after  recognition  of  aneurism. 

1  case.     Died  from  asphyxia  caused  by  pressure  of  sac,  eight  years. 

1  case.  Died  from  external  rupture  of  sac  two  years  and  eight  months  after  recog- 
nition of  aneurism. 

1  case.     Died  from  exhaustion  from  pressure  of  sac,  two  years  after  recognition. 

1  case.     Died  from  dysj)ncea  from  pressure  of  sac,  two  years  after  recognition. 

1  case.  Died  from  dyspnoea  and  exhaustion  from  pressure  of  sac,  one  year  and  a 
half  after  recognition. 

1  case.     Died  from  rupture  of  sac  into  lungs,  one  year  and  a  half  after  recognition. 

1  case.  Died  from  rupture  of  sac  into  lungs  eight  months  and  a  half  after  recog- 
nition. 

1  case.  Died  from  rupture  of  sac  into  tissues,  becoming  diffused,  and  causing  death 
by  pressure,  five  months  and  a  half  after  recognition. 

1  case.     Died  from  rupture  of  sac,  death  by  pressure,  five  months  after  recognition. 

1  case.  Died  suddenly  (probably  from  cerebral  clot)  one  year  and  a  half  after 
recognition. 

1  case.     Died  suddenly,  cause  not  stated,  not  rupture  of  sac. 

2  cases.   Died  from  rupture  of  popliteal  aneurisms. 

1  case.     Died  from  typhoid  pneumonia,  three  years  after  recognition. 

Of  the  four  cures,  three  remained  well ;  one  died  about  four  years 
later  from  rujDture  of  an  aortic  aneurism.  Of  these  eighteen  fatal  cases 
in  which  no  treatment  was  undertaken,  three  died  of  other  disease  than 
the  aneurism. 

Of  the  thirteen  cases  in  which  the  duration  of  life  is  noted  after  the 
recognition  of  the  aneurism,  the  sum  total  is  forty-seven  years  and  nine 
months. 

The  sum  of  life  in  the  thirteen  cases  after  deligation  of  the  innominate 
is  about  eight  months,  a  difference  in  favor  of  non-interference  (in  an 
equal  number  of  cases)  of  about  forty-seven  years  of  Life. 


St:s^opsis  of  14  Cases  treated  by  Valsalva's  Method. 

{More  or  less  modified.) 

1  case.  M.  ;  R.  Subclavian  aneurism.  Size,  hen's  egg.  Venesection  ;  cold  and 
lead  lotion  locally.  Recovered.  Two  and  a  half  years  later  was  work- 
ing as  a  carter  in  the  city. 

1  case.  M.  ;  R.  Subclavian.  Immense  size.  Venesection.  Cold  and  astringents 
locally.  Tumor  reduced  in  size  and  firmer  ;  lost  sight  of  while  in  pro- 
cess of  cure. 

1  ease.  M.  ;  R.  Subclavian  (syphilitic).  Valsalva's  method  and  antisypbilitics. 
Cure  complete. 

1  case.  M.  ;  R.  ;  age  forty-five.     Subclavian  (syphilitic).     Valsalva's  method  and 
antisypbilitics.     Cured  and  seen  well  six  years  later. 
15 


226  A  TEXT-BOOK   ON  SURGERY. 

1  case.  M.  ;  age  forty-two.  Subclavian.  Venesectiou.  Digitalis.  Rest.  Marked 
improvement,  so  that  patient  left  hospital  and  was  lost  sight  of. 

1  case.  M.  ;  age  fifty.  Subclavian.  Was  treated  for  an  intercurrent  attack  of 
rheumatism  by  rest,  strict  diet,  and  antiphlogistics.     Cured. 

1  case.  M.  ;  age  thirty-nine.  Subclavio-axillary  (Pancoast's  case).  Valsalva's 
method  had  been  tried  and  considered  a  failure.  Operation  determined 
on.  Carried  into  operating-room.  Patient  fell  into  collapse  and  opera- 
tion was  postponed.  Recovered  cured.  (It  is  stated  that  a  large  dose 
of  aconite  had  been  given  by  mistake  just  before  the  oj)eration  was  to 
have  taken  place.) 

1  case.  M.  ;  age  thirty-seven.  Subclavian.  Venesection.  Valsalva's  method  and 
caref  id  and  persistent  direct  compression  for  one  year  and  a  half.    Cured. 

1  case.  M.  ;  age  fifty-one.  Subclavio-axillary  (by  Pelletan).  Valsalva's  method. 
Cured. 

5  cases  treated  by  this  method  (in  part)  were  fatal.  Venesection  was  not  practiced 
except  in  one  case.  Only  local  and  constitutional  treatment.  All  died 
within  twelve  months  of  the  recorded  recognition  of  the  disease  ;  one 
from  ulceration  into  trachea,  haemoptysis,  and  exhaustion  ;  two  from 
external  bursting  of  sac  ;  two  from  exhaustion  and  coma  (with  pressure 
on  the  trachea  in  one  case). 

Summary. — Fourteen  cases.  Cured,  seven  ;  improved,  and  in  process 
of  cure  when  lost  sight  of,  two ;  died,  five.  No  venesection  in  four  of 
five  fatal  cases.     One  successful  case  modified  by  direct  pressure. 


Synopsis  of  6  Cases  treated  by  Dieect  Peesstjre  upon  the 
Sac  (Modifications  given). 

(All  subclavian  aneurism.) 

1  case.  M. ;  forty-six  years  ;  R.  Leather  "  cup  "  molded  over  tumor  and  held  in 
place  by  figure-of-8  straps  around  shoulders  and  axilla.  Cured  in  four- 
teen months.  Did  light  work  during  treatment,  and  had  no  other  medi- 
cation. 

1  case.  M.  ;  thirty-nine  years  ;  L.  Enormous  size.  Treated  by  cold  and  pressure 
"  in  turns."  Small  cannon-ball  suspended  so  as  to  press  comfortably. 
Discharged  relieved.  Some  months  later  violent  inflammation  (from 
fall),  suppuration,  rupture  of  sac  ;  discharged  two  quarts  of  pus  and 
blood.     Cured.     Debility  of  arm  probably  permanent. 

1  case.  M.  ;  forty-one  years.  (Thirteen  months'  duration.)  Kept  in  bed,  on  back  ; 
ice  locally  ;  restricted  diet.  Third  day  air-cushion  for  twelve  hours, 
with  intermissions  amounting  to  three  hours.  Every  half-hour  interval 
of  ice.  Treatment  for  seven  days.  Tumor  began  to  subside,  and  was 
cured  in  twelve  months. 

1  case.  (T.  Holmes.)  ("Lancet,"  February  12,  1876,  p.  237.)  Subclavian.  Treated 
by  direct  pressure  from  rubber-ball.     Cured. 

1  case.   (Dupuytren.)     Direct  pressure.     Resulted  fatally. 

1  case.  (Porter.)  Exposed  axillary  and  passed  needle  under  it.  Thirty-five  days 
later  exposed  innominate  and  passed  the  "  acupressure  needle  "  under  it. 
Died  from  haemorrhage  from  innominate  on  tenth  day. 


SPECIAL  AXEURISMS.  227 

(In  one  case  given  in  preceding  table,  direct  pressure  was  practiced 
with.  Yalsalva's  method.) 

Sitmmary. — Five  cases  of  ''direct  pressure"  (without  operative  pro- 
cedures).    Cured,  four  ;  died,  one. 

St^'OPSIS  of  Cases  of  Massage  oe  Kxeadiis'G  ry  the  TEEATirE^'T  of 

SirBCLAYIAJS'   A>.-EUEISiI. 

Of  this  method  there  are  six  cases. 

Three  cured  ;  viz.,  by  Fergusson,  Little,  and  Porter. 
Three  died  ;  viz.,  by  Fergusson,  Hilton,  and  Morgan. 

(See  "Guy's  Hospital  Reports,"  vol.  xvi,  p.  42  et  seq.) 

In  addition,  Mr.  Bryant,  in  his  "  Practice  of  Surgery,"  p.  190,  gives  a 
case  by  Dutoit,  of  Berne,  in  which  a  subclavian  aneurism  was  cured  by  in- 
jection of  ergotin  around  the  sac  under  the  skin,  and  digital  compression. 

Poland  cured  one  case  by  digital  pressure  on  cardiac  side.  A  third  case 
was  tried  for  forty-six  hotirs  and  abandoned  on  account  of  j^ain  from  press- 
ure. The  patient  died  from  exhaustion.  Paget  tried  mechanical  pressure 
in  a  fourth  case,  but  abandoned  it  as  a  hopeless  undertaking.  A  fifth  case 
by  Verneuil  was  improved,  but  lost  sight  of  before  a  cure  was  effected. 

From  the  study  of  the  foregoing  history  of  subclavian,  subclavio- 
axillary,  and  axillary  aneurism,  I  have  reached  the  following  conclusions  : 

DeUgation  of  the  innominate  artery,  or  the  subclavian  in  its  first  sur- 
gical division,  are  operations  so  dangerous  that  they  should  be  under- 
taken only  in  extreme  conditions. 

The  first  indication  in  the  treatment  of  these  lesions  is  pressure,  judi- 
ciously apjilied.  If  possible,  the  compression  should  be  exercised  be- 
tween the  tumor  and  the  heart.  Xext  in  preference,  direct  pressure  upon 
the  body  of  the  aneurism.  Perfect  and  persistent  rest  should  be  enforced, 
and  with  this  the  method  of  Tuffnel  offers  the  surest  and  safest  means  of 
palliation  and  cure. 

In  making  direct  compression,  the  elastic  ball  introduced  by  ilr. 
Holmes  seems  best  adapted.  This  should  be  applied  gradually,  in  order 
to  accustom  the  patient  to  its  presence.  Massage  is  so  inferior  to  the 
plan  just  detailed  that  it  may  be  omitted  from  practice. 

Should  all  these  means  fail  after  a  persistent  trial,  should  the  sac  by 
ulceration  open  and  threaten  instantaneous  death,  or  should  the  surgeon, 
from  the  ai^pearances,  judge  that  this  accident  was  on  the  eve  of  occur- 
ring, ligature  of  the  innominate  should  be  performed,  provided  that  the 
ligature  could  not  be  applied  to  the  subclavian  proper. 

"When  the  aneurism  involves  the  last  portion  of  the  subclavian  or  the 
axillary,  the  ligature  may  be  applied  to  the  third  division  of  the  sub- 
clavian. Compression  should  always  be  tried  in  these,  as  in  all  other 
cases,  before  resorting  to  the  ligature. 

Aneurism  of  the  brachial,  radial,  and  ulnar  arteries,  or  their  branches, 
is  compararively  rare,  and  when  seen  is  almost  always  the  result  of  a 
wound.  The  diagnosis  is  not  difficult.  The  treatment  required  is  digital 
or  mechanical  compression  on  the  cardiac  side  of  the  tumor.     If  this  fail. 


228  A  TEXT-BOOK   ON   SXJRGEKY. 

direct  compression  of  the  sac  may  be  added,  and,  if  a  thorougli  trial  of 
these  two  methods  is  not  successful,  a  catgut  ligature  should  be  applied, 
after  the  method  of  Hunter. 

Aneurism  of  the  Vertebral  Artery. — Aneurism  of  the  vertebral  is 
almost  always  the  result  of  a  punctured  wound.  A  rare  exception  to  this 
rule  is  the  case  of  idiopathic  aneurism  of  both  vertebrals  reported  by  Dr. 
Anderton,  of  New  York  city.*  It  occiirs  most  frequently  in  that  portion 
of  the  vessel  between  the  atlas  and  the  transverse  process  of  the  sixth 
cervical.  The  chief  point  in  diagnosis  is  the  diiferentiation  between  the 
lesion  in  question  and  carotid  aneurism. 

The  difficulty  of  distinguishing  vertebral  from  carotid  aneurism  in  the 
neck  arises  from  the  fact  that  direct  pressure  from  before  backward,  in 
the  lower  portion  of  the  neck,  will  interfere  with  or  arrest  pulsation  in 
aneurisms  of  both  vessels. 

If,  however,  the  head  be  flexed  upon  the  chest,  and  the  sterno-mastoid 
muscle  thus  relaxed,  the  carotid  can  be  compressed  by  grasping  the  mus- 
cle between  the  thumb  and  flnger,  which  are  pressed  deeply  behind  the 
outer  and  inner  borders.     This  will  not  involve  the  vertebral. 

Again,  if  the  carotid  be  forcibly  compressed  by  the  thumb,  backward 
and  inward,  against  the  vertebral  column,  at  any  point  above  the  trans- 
verse process  of  the  sixth  cervical,  the  vertebral  will  not  be  included, 
since  it  is  protected  -by  the  processes. 

In  my  Essays  are  recorded  live  cases  in  which  the  common  carotid  was 
tied  for  supposed  carotid,  but  in  reality  vertebral,  aneurism.  All  ended 
iatally. 

In  the  treatment  of  this  lesion  direct  pressure  may  be  enqjloyed,  since 
prolonged  compression  of  the  artery  before  it  enters  the  foramen  in  the 
sixth  transverse  process  is  impossible.  One  successful  result  of  this 
method  is  recorded.  If  the  disease  continues  to  increase,  deligation  of 
the  vessel  in  its  first  portion  may  be  effected.  This  is  a  very  difficult 
operation,  and  has  rarely  been  attempted.  The  only  operators  so  far  are 
Smyth,  Parker,  Alexander,  and  myself. 

Aneiirism  of  the  internal  mammary,  and  other  smaller  branches  of 
the  subclavian,  does  not  demand  separate  consideration.  Aneurism  of 
the  intercostal  arteries  occurs  in  rare  instances,  usually  as  a  result  of 
fracture  of  a  rib  or  a  stab- wound. 

Aneurism  of  the  Abdominal  Aorta. — Aneurismal  dilatation  of  this 
section  of  the  aorta  occurs  most  frequently  near  the  diaphragm.  The 
entire  vessel  may  be  the  seat  of  fusiform  aneurism.  Females  are  less 
frequently  attacked  than  the  oj)posite  sex.  In  corpulent  persons  the 
diagnosis  is  difficult.  Tumors  of  the  central  organs,  as  the  stomach,  pan- 
creas, transverse  colon,  and  the  superjacent  mesentery,  may  be  mistaken 
for  aneurism.  On  the  other  hand,  in  emaciated  persons,  unnatural  ex- 
pansion of  the  aorta  during  the  cardiac  systole  has  led  to  a  mistake  in 
diagnosis.  The  history  of  the  development  of  the  tumor,  the  presence  of 
the  aneurismal  tremor  and  bruit,  and  the  recognized  general  expansion  of 

*  "  Medical  Record,''  vol.  xx,  p.  354. 


t 


SPECIAL   ANEURISMS. 


229 


the  sac,  vriih  the  arterial  pulse,  will  enable  the  carefiil  observer  to  arrive 
at  a  correct  diagnosis. 

The  treatment  is  chiefly  expectant.  The  method  of  Tufl'nel,  combined 
with  interrupted  compression  by  means  of  the  tourniquet,  should  be  em- 
ployed. Pressure  may  be  cardiac,  direct,  or  distal,  the  former  being 
preferable,  if  the  location  of  the  tumor  renders  it  possible.  If  operative 
interference  is  demanded,  the  introduction  of  juniperized  catgut  ligatures 
through  the  canula,  heretofore  described,  would  be  advisable.  Anaesthesia 
is  requii'ed,  and  the  duration  of  compression  may  vary  from  fifteen  min- 
utes to  one  hour.  Deligation  of  the  aorta  for  aneurism  of  the  same  is 
scarcely  possible. 

Aneurism  of  tJie  Brandies  of  the  Abdominal  Aorta. — Aneurism  of 
any  of  the  visceral  or  parietal  branches  of  the  abdominal  aorta  may  occur. 
The  location  of  the  tumor  and  the  characteristic  symptoms  of  aneurism 
will  point  to  the  vessel -affected.  When  treatment  is  necessary,  the  same 
method  should  be  emi^loyed  as  for  aneurism  of  the  main  trunk.  Explo- 
ration under  strict  antisepsis  may  be  made,  and  deligation  with  the  ani- 
mal ligature  practiced,  if  the  tumor  is  sufficiently  removed  fi"om  the  aorta 
to  allow  the  apphcation  of  the  ligature  to  non-diseased  tissue. 

Aneurism  of  tJie  Iliac  Arteries. — Aneurism  of  the  common,  external,  or 
internal  iliac  arteries  is,  fortunately,  of  rare  occuiTence.  The  diagnosis  may 
be  made  by  a  study  of  the  history  of  the  indi\'idual  case,  and  by  abdomi- 
nal palpation,  coupled  with  physical  exploration  by  the  rectum  or  vagina. 

In  the  treatment  of  aneurism  of  the  common  iliac,  compression  of  the 
abdominal  aorta  should  be  faithfully  tried.  With  this  may  be  combined 
the  treatment  by  rest  and  restricted  diet,  and  carefully  graduated  direct 
pressure.  Should  these  methods  prove  useless,  and  death  be  imminent  from 
rapid  expansion  and  threatened  rupture  of  the  sac,  deligation  of  the  abdom- 
inal aorta  may  be  performed,  or  the  external  iliac  or  femoral  may  be  tied. 

The  abdominal  aorta  has  been  tied  in  the  following  cases  of  iliac 
aneurism :  * 


Operator. 


Date. 


Astley  Cooper.  1817 

James 1829 

Murray lS3-i 

Alonteiro lSi2 

South 1856 

ilcGuire ,  1863 

Watson I  1S69 

Stokes !  1869 


if. 

■14 

ir. 

33 

ii. 

31 

SI. 

28 
30 

11. 

9 

M. 

50 

Died  in  forty  hours.  Ligature  applied  three  fourths  of  an  inch 
above  bifurcation  of  aorta.  Tumor  measured  eight  inches  in 
long  axis. 

Died  in  three  and  one  half  hours.  Femoral  tied  thirty-three  days 
before  aorta.  Tumor  increased  in  size  and  aorta  tied.  Liga- 
ture applied  seven  eighths  of  an  inch  above  bifurcation. 

Died  in  twenty-three  hours.  Tumor  extended  as  high  as  the 
umbilicus.  External  iliac  involved.  Gangrene  was  threat- 
ened.    Ligature  half  an  inch  above  bifurcation. 

Died  in  ten  days.  Large  diffuse  aneurism  of  femoral.  Aorta 
ulcerated  at  seat  of  ligature,  and  death  took  place  from 
haemorrhage. 

Died  in  forty-three  hours.     External  and  common  iliac  involved. 

Died  in  eleven  hours.  Sac,  which  involved  loth  common  iliacs, 
burst  during  operation,  when  a  hasty  ligature  was  thrown 
around  the  aorta. 

Died  in  sixty-five  hours.  Sine  weeks  after  ligature  of  common 
iliac  hcemorrhage  occurred,  when  aoria,  external  and  internal 
iliacs  were  tied.     Xo  hfemorrhage  after  operation. 

Died  in  twelve  hours.  Eight  common  and  external  iliac  and 
femoral  involved. 


■  Gross's  "  Sy.stem  of  Surgery." 


230  A  TEXT-BOOK   ON  SURGERY. 

When  the  aneurism  is  located  ixpon  the  external  iliac,  compression 
with  the  tourniquet  may  be  employed  over  the  aorta  or  common  iliac 
artery.  Prof.  Sands  has  advised  and  practiced  digital  pressure  of  the 
common  iliac  by  means  of  the  hand  introduced  into  the  rectum.  Pressure 
from  within  the  rectum  may  also  be  accomplished  by  means  of  a  bougie 
or  piece  of  wood  properly  padded  (Davy's  method).  As  a  last  resort  the 
common  iliac  may  be  tied.  This  operation,  though  dangerous,  has  been 
successfully  accomplished  in  several  instances  in  late  years.  A  patient 
recently  operated  upon  by  Dr.  Lange,  of  New  York,  recovered  and  was 
cured.  Aneurism  of  the  internal  trunk  is  amenable  to  treatment  by  com- 
pression of  the  aorta  or  common  iliac,  or  by  deligation  of  the  primitive 
trunk. 

Aneurism  of  the  branches  of  this  vessel  usually  occurs  in  the  gluteal 
and  sciatic.  The  origin  is  almost  invariably  traumatic.  The  earliest 
symptoms  are  referable  to  the  presence  of  the  tumor.  It  must  be  distin- 
guished from  abscess  or  hernia.  Aspiration  would  determine  the  presence 
of  the  former,  and  the  symptoms  of  hernia,  with  absence  of  pulsation, 
would  indicate  the  escape  of  the  viscera  through  the  great  sciatic  fora- 
men. The  treatment  is  difficult  and  often  ineffectual.  Direct  compres- 
sion should  be  first  tried.  Incision  into  the  sac,  turning  out  the  clot,  and 
tying  both  ends,  has  been  successful  in  four  of  six  cases  reported  by 
Fischer.  The  ligature  may  also  be  applied  between  the  sac  and  the  point 
of  exit  of  the  artery,  or,  as  a  last  effort,  the  common  iliac  may  be  tied. 

Aneurism  of  the  Femoral  Arteries. — Aneurism  of  the  superficial 
femoral  artery  is  comparatively  frequent.  It  occurs  by  preference  in 
the  upper  half  of  the  artery,  and  in  males  in  the  great  majority  of  in- 
stances.    In  rare  instances  the  disease  is  symmetrical. 

The  diagnosis  is  not  difficult,  since  the  expansile  pulsation  of  the 
tumor  can,  in  most  cases,  be  readily  appreciated  by  palpation.  A  tumor 
in  the  line  of  the  artery,  with  the  characteristic  pulsation,  tremor,  and 
murmur,  all  of  which  signs  disappear  when  the  iliac  artery  or  aorta  is 
firmly  compressed,  point  almost  unerringly  to  a  diagnosis.  The  greatest 
danger  of  error  lies  in  the  presence  of  an  abscess.  Abscess  is,  however, 
of  rare  occurrence  in  this  region,  except  as  a  sequence  of  spinal  caries  or 
hii3-joint  disease,  and  these  conditions,  existing  with  the  other  common 
symptoms  of  the  development  of  abscess,  would  lead  to  its  recognition. 
If  doubt  should  still  exist,  after  even  the  most  careful  survey  of  the  case, 
the  hypodermic  needle  would  settle  the  diagnosis. 

Treatment. — Aneurism  of  Xh^  femoral  artery  will,  in  the  vast  majority 
of  cases,  yield  to  judicious  and  patient  comj^ression.  "When  the  tumor 
extends  as  high  as  Poupart's  ligament,  or  above  this  point,  the  chances 
of  success  are  diminished,  since  pressure  will  have  to  be  applied  to  the 
common  or  external  iliac  or  the  aorta.  Under  such  conditions  direct 
compression,  by  means  of  Holmes's  elastic  ball,  applied  so  gradiially  that 
inflammation  of  the  sac  will  not  be  precipitated,  should  be  first  faithfuUy 
tried.  Ligature  of  the  common  or  external  iliac  should  be  deferred  until 
all  other  remedies  have  failed,  and,  when  there  is  a  choice  between  these 
two  procedures,  the  deligation  of  the  external  iliac  should  be  preferred, 


SPECIAL   AXErRISMS.  031 

on  account  of  the  anastomoses  of  tlie  brandies  of  tlie  infernal  iliac  Trith 
the  vessels  of  the  thigh.  Direct  compression  of  the  sac  was  once  success- 
fully practiced  by  Dr.  Brown,  of  Boston,  in  a  case  of  femoral  aneurism 
at  Ponpart's  ligament.  The  weight  employed  may  be  as  much  as  twelve 
pounds.  Iron  balls  were  used  in  this  case.  The  patient  was  confined 
to  bed  for  ten  months.  When  the  tumor  is  so  far  away  from  Poupart's 
ligament  that  digital  or  mechanical  compression  of  the  femoi-al  iipon 
the  OS  pubis  is  possible,  this  treatment  should  be  adopted.  Extreme 
flexion  of  the  thigh  upon  the  abdomen  has  succeeded  in  producing  a  cure 
in  a  few  instances.  Direct  pressure  upon  the  tumor,  with  the  limb  ex- 
tended, is  less  painful  and  equally  efficacious.  When  the  necessity  for 
the  application  of  the  ligature  occurs,  the  effort  should  be  made  to  reach 
the  artery  below  the  origin  of  the  prof  unda  fernoris,  since  the  danger  of 
gangrene  is  much  less  if  this  great  collateral  route  is  open. 

The  treatment  of  aneui'ism  of  the  lower  portion  of  the  femoral  does 
not  materially  differ  fi'om  the  above. 

Aneurism  of  the  profunda  femoris  is  rare,  occurring  usually  as  a 
complication  of  this  condition  in  the  common  ti-unk.  or  as  a  result  of  a 
punctured  wound. 

The  treatment  will  include  pressure  on  the  cardiac  side,  or  direct 
compression,  and,  as  a  last  resort,  ligature  of  the  common  femoral, 
or  Uiac. 

Aneurism  oftTie  Popliteal  Artery. — About  one  fourth  of  all  aneurisms 
occur  in  this  vessel.  Subjected,  by  reason  of  its  unfortunate  locarion.  to 
the  accidents  of  compression  in  extreme  flexion  of  the  leg,  it  fi'equently 
suffers  those  pathological  changes  which  end  in  aneurismal  dilatarion, 
and  is  ordy  second  in  order  of  frequency  to  the  aorric  arch,  which  yields 
to  the  violence  of  the  cardiac  systole.  As  with  aneurism  in  other  loca- 
tions, it  occurs  most  frequently  in  males,  and  in  the  active  period  of  life. 
being  rare  in  childhood  and  youth,  and  most  common  in  the  years  fi'om 
twenty -five  to  fifty. 

Diagnosis. — On  account  of  the  infrequency  of  tumors  in  this  region, 
other  than  aneurism,  the  diagnosis  is  not  difficult.  The  characteristic 
symptoms  of  this  malady  will  determine  its  differentiation  from  glandular 
enlargements,  exostoses,  over-distended  bursse,  or  abscess. 

Treatraent. — In  the  treatment  of  popliteal  aneurism  the  patient  should 
be  placed  in  the  recumbent  posture,  with  the  leg  of  the  affected  side 
slightly  flexed.  A  soft  mattress  should  be  used,  and  the  thigh  and  leg 
held  in  a  comfortable  and  fixed  position  by  means  of  a  pillow  under  the 
popliteal  space,  and  sand-bags  laterally.  Under  the  influence  of  an 
opiate,  or  in  extreme  cases  complete  etherization,  digital  or  mechanical 
pressure  should  be  employed  upon  that  portion  of  the  artery  lying  in 
Scarpa's  triangle  (Fig.  273).  Within  this  limit  the  point  of  compression 
may  be  shifted,  in  order  to  prevent  too  great  local  irritation. 

In  obstinate  cases  compression  on  the  cardiac  side  may  be  re-enforced 
by  forced  flexion  of  the  leg  on  the  thigh,  or  by  direct  pressure  upon  the 
tumor.  The  instances  wdl  be  exceedingly  rare  where  a  patient  and  skill- 
ful employment  of  these  methods  of  compression  %vill  not  succeed  in 


232  A  TEXT-BOOK   ON    SURGERY. 

effecting  a  cure.  Consolidation  may  result  in  one  or  two  hours,  or  it  may 
require  several  hours  or  days.  Acupressure  and  massage  are  not  to  be 
employed.  The  elastic  bandage  of  Esmarch  has  not  given  results  vs^hich 
would  justify  its  further  use.  When  compression,  either  on  the  cardiac 
side  or  directly  upon  the  aneurism,  fails,  the  deligation  of  the  femoral, 
in  the  extreme  lower  angle  of  Scarpa's  space,  is  demanded. 

Aneurism  beyond  the  Popliteal. — Aneurism  of  the  peroneal  or  tibial 
arteries,  or  their  branches,  is  rare.  In  diagnosis  and  treatment  this  lesion, 
when  situated  in  this  portion  of  the  arterial  system,  requires  little  or  no 
special  consideration.  When  the  tumor  is  so  situated  that  the  vessel 
immediately  involved  can  not  be  occluded  by  compression,  this  may  be 
directed  to  the  femoral,  or,  in  aneurisms  of  small  size,  direct  pressure 
may  be  sufficient  to  effect  a  cure.  The  ligature  will  be  demanded  if  other 
methods  fail. 

Arterio-venous  Aneurism.  —  Arterio-venous  aneurisms  are  of  two 
kinds.  In  one  variety  the  communication  is  direct,  the  contiguous  walls 
of  the  artery  and  vein  being  closely  adherent  immediately  around  the 
opening  leading  from  one  vessel  to  the  other.  This  is  called  direct  arterio- 
venous aneurism,  or  aneurismal  varix. 

When  a  sac  intervenes  it  is  called  an  indirect  arterio-tenous  or  vari- 
cose aneurism  (Fig.  271). 

The  cause  is  usually  traumatic,  resulting  most  frequently  from  punct- 
ured wounds,  although  any  inflammatory  process  which  induces  necrosis 
of  the  arterial  and  venous  walls  may  lead  to  this  form  of  aneurism.  In 
exceptional  instances  the  communication  has  either  not  been  established, 
or  at  least  has  escaped  observation  for  several  years  after  the  injury. 
This  lesion  may  occur  in  any  portion  of  the  economy.  In  former  years 
it  was  observed  most  frequently  in  front  of  the  elbow-joint,  where  it  was 
produced  by  the  accidental  puncture  of  the  brachial  in  the  operation  of 
venesection.  It  occurs  not  infrequently  in  the  neck,  as  a  result  of  wound 
of  the  carotid  artery  and  internal  jugular  vein. 

The  chief  points  in  the  differential  diagnosis  between  varicose  aneu- 
rism and  aneurismal  varix  are  the  presence  of  a  tumor  and  the  peculiar 
aneiirismal  hru  it  and  tremor,  which  conditions  exist  in  the  former. 

In  both  varieties  of  this  disease  the  veins  become  greatly  distended 
and  tortuous,  and  pulsate  forcibly  with  each  contraction  of  the  heart, 
while  the  pulsation  in  the  artery  beyond  the  lesion  is  perceptibly  dimin- 
ished. 

In  the  treatment  of  varicose  aneurism,  compression  of  the  artery  should 
be  employed  on  both  sides  of  the  tumor,  while  direct  pressure  should  be 
made  iipon  the  sac,  between  the  two  vessels.  When,  from  the  location 
of  the  lesion,  this  method  is  not  feasible,  or  when,  after  a  faithful  trial, 
it  has  failed  to  produce  a  consolidation  of  the  aneurism,  the  ligature  will 
be  required.  Catgut  should  be  used,  one  thread  being  passed  around  the 
artery  just  above,  and  another  just  below  the  tumor.  When  so  situated 
that  the  vein  involved  in  the  lesion  is  not  necessary  to  the  integrity  of  the 
part,  as  in  the  forearm,  this  may  also  be  secured  on  the  distal  side  of  the 
foramen  of  communication. 


SPECIAL   AXEURISilS. 


233 


^ 


Operative  interference  ia  cases  of  aneurismal  tarix  is  not  so  fre- 
quently indicated  as  in  varicose  aneurism,  omng  to  the  comparatiTely 
slow  progi'ess  of  the  disease.  Experience  has  shown  that  deligation  of  the 
affected  artery  is  far  more  dangerous  in  this  condition  than  in  the  indirect 
variety.  Fatal  secondary  hsemoiThage  is  recorded  in  a  number  of  in- 
stances, while  in  others  gangrene  has  resulted  from  closure  of  the  artery. 
Compression  should  be  employed  as  in  the  treatment  of  the  form  just 
considered.  "When  the  lesion  is  situated  in  the  vessels  of  an  extremity 
much  comfort  may  be  secured  by  the  employment  of  an  elastic  bandage 
or  stocking,  as  in  the  treatment  of  venous  varix.  As  a  last  resort,  ampu- 
tation may  be  pi-acticed. 

The  Author's  Case  of  Deligafio/i  of  the  Left  Suidavian  and  Left 
Common  Ca.rotid  Arteries.'^ — In  February,  1889,  under  chloroform  nar- 
cosis, I  tied  with  catgut  ligatures  the  left  common  carotid  and  left  sub- 
clavian artery  (third  division)  for  the  cure  of  aneurism  of  the  transverse 
arch.  The  patient,  male,  forty-eight 
years  old,  had  syphilis  seventeen  years 
before,  had  neglected  treatment,  and 
syphilitic  arteritis  ensued.  Symptoms 
of  aneurism  appeared  about  two  years 
before  date  of  operation.  The  iodides 
had  been  faithfully  ti-ied,  but  the  symp- 
toms of  pressure  by  the  tumor  increased, 
and  the  operation  was  done  as  a  last 
resort.  He  died  seventy-two  hours  later 
from  suppression  of  urine  and  asphyxia, 
due  to  syphilitic  gummata,  involving 
chiefly  the  right  lung,  which  was  almost 
entirely  solidified.  Commencing  with 
the  origin  of  the  left  carotid  and  ex- 
tending beyond  that  of  the  left  subclav- 
ian was  situated  a  spherical  aneurism 
about  three  inches  in  diameter  filled 
with  firm  clot  almost  wholly  organized. 
It  pressed  heavily  on  the  trachea  and 
oesophagus  and  the  left  recuiTent  laryn- 
geal nerve.  It  extended  from  the  sev- 
enth cervical  to  the  second  dorsal  vertebra  (Fig.  276  a).  This  aneurism 
was  pracrically  cured,  and  the  organized  clot  had  without  doubt  resulted 
from  the  medical  and  expectant  treatment.  The  smaller  proportion  of 
softer  and  recent  clot  was  prodticed  by  the  ligature. 


\ 


Fig.  276  a. — ^The  anthor's  ease  of  deligation 
of  the  left  carotid  and  left  subclavian  ar- 
teries for  aneurism  of  the  transverse  por- 
tion of  the  arch. 


*  A  recent  and  sncoessfal  case  of  deligation  of  the  risht  common  carotid  and  snbcla\-ian 
arteries  for  anenrism  of  the  arch  is  reported  by  Dr.  F.  T.  Meriwether,  of  Asheville,  X.  C, 
in  "Annals  of  Surgerv,"  Mav.  1889. 


16 


CHAPTER  XI. 

LIGATION   OF  ARTERIES. 

Operative  Surgery  of  the  Arteries. — In  tying  an  artery,  all  of  the  de- 
tails of  the  antiseptic  method  given  heretofore  should  be  scrupnlously 
carried  out.     While  the  incision  should  be  along  the  line  of  the  artery, 


it  should  lean  as  far  from  the  accompanying  vein  as  possible.     In  ap- 
proaching the  vessel  after  the  skin  is  divided,  the  fascia  and  all  inter- 


FiG.  278. 


venmg  tissues  should  be  grasped  between  two  long,  delicate  dissecting 
forceps  (Figs.  277,  278),  until  the  sheath  is  reached,  and  this  is  opened 


LIGATION   OF  ARTERIES.  235 

in  the  same  maimer.  As  soon  as  the  wall  of  the  artery  is  exposed  the 
sharp-pointed  instruments  should  be  laid  aside.  A  dull-pointed  aneu- 
rism-needle (Fig.  63),  or  a  flexible  silver  probe,  should  now  be  passed 
between  the  sheath  and  the  vessel,  and  carried  carefully  around  the 
artery,  keeping  the  point  close  to  the  wall  of  the  vessel.  When  a  nerve 
or  vein  is  in  close  relation,  the  instrument  should  be  introduced  on  the 
side  nearest  these,  thus  insuring  their  exclusion.  The  dull-pointed 
probe,  bent  to  the  proper  cnrve,  may  be  used  to  great  advantage  in 
almost  all  operations  upon  the  arteries.  After  the  point  is  carried 
around  the  vessel  and  brought  up  out  of  the  sheath,  the  ligature  may  be 
tied  over  the  slight  bulbous  expansion  of  this  instrument,  which,  when 
withdrawn,  leaves  the  ligature  around  the  vessel.  The  force  employed 
should  be  sufficient  to  occlude  the  vessel,  yet  not  enough  to  inflict  unne- 
cessary violence  upon  its  walls.  The  ends  of  the  string  should  be  cut 
off  for  one  fourth  to  one  half  of  an  inch  from  the  knot,  and  the  wound 
closed  for  a  permanent  dressing. 

Ligation  of  the  Innominate  Artery — Anatomy. — The  arteria-innomi- 
nata  is  derived  from  the  transverse  segment  of  the  arch  of  the  aorta, 
immediately  in  front  of  the  trachea.  Just  behind  the  middle  of  the  ster- 
num, at  a  level  varying  from  one  half  to  one  and  a  half  inches  below  the 
upper  margin  of  the  manubrium. 

From  this  origin  it  travels  obliquely  upward,  backward,  and  to  the 
right  (crossing  the  trachea  from  its  center),  and  bifurcates,  near  the 
upper  margin  of  the  clavicle,  between  the  sternal  and  clavicular  origins 
of  the  sterno-mastoideus  into  the  carotid  and  suhclaman  arteries.,  the 
first  of  these  coming  from  its  anterior  aspect,  the  last  a  direct  continu- 
ation of  the  arch  of  the  innominate.  The  innominata  in  rare  instances 
originates  to  the  left  of  the  trachea ;  more  frequently  it  is  given  off  be- 
fore it  reaches  the  windpipe.  As  a  rule,  it  is  longer  in  females  than 
in  males. 

In  twenty-eight  cases  in  which  I  measured  the  distance  of  the  origin 
of  the  innominate  from  the  commencement  of  the  aorta,  the  average 
was  three  inches  and  a  half.  In  thirty-seven  measurements  made  to 
determine  the  length  of  the  innominate  artery,  the  average  was  one  inch 
and  a  half,  the  shortest  specimens  being  three  fourths  and  the  longest 
two  inches. 

Operation. — Place  a  firm  cushion  crosswise  beneath  the  shoulder- 
blades,  so  that  the  head  will  fall  well  back,  and  thus  draw  the  artery 
upward.  Have  an  assistant  draw  the  arm  and  shoulder  of  the  right  side 
forcibly  downward,  while  the  chin  is  elevated  and  the  face  turned  slightly 
to  the  left. 

With  the  patient  completely  aufesthetized,  and  every  arrangement 
made  for  expedition,  make,  from  the  center  of  the  interclavicular  notch, 
an  incision  about  three  inches  in  extent  along  the  clavicle.  A  second 
incision,  commencing  at  the  inner  border  of  the  sterno-mastoideus,  about 
two  inches  and  a  half  above  the  clavicle,  is  made  to  unite  with  the  first 
incision  at  the  middle  of  the  interclavicular  notch.  Dissect  the  flap  up- 
ward until  the  sterno-mastoid  muscle  is  exposed,  the  sternal  and  two 


236 


A  TEXT-BOOK   ON   SURGERY. 


thirds  of  the  clavicular  origins  of  which  should  be  divided  upon  a  grooved 
director  carefully  introduced.  Superficial  to  the  muscle  some  small  veins 
will  be  found,  and  underneath  its  clavicular  portion  is  the  junction  of 


Fig.  279. — Showing  the  relations  of  the  parts  involved  in  deligation  of  the  innominate  artery ;  the  right  sub- 
clavian and  carotid  in  their  hrst  divisions. 


the  subclavian  and  jugular  veins,  in  dangerous  proximity.  The  anterior 
jugular  veins  will  be  seen  immediately  beneath  the  muscle,  and  should 
be  tied  and  divided.  Dissecting  carefully,  with  the  handle  of  the  scalpel, 
the  connective  and  areolar  tissue  in  which  these  veins  are  imbedded,  the 


LIGATION  OF  ARTERIES.  237 

origins  of  the  sterno-Tiyoid  and  sterno-tliyroid  miascles  will  be  reached, 
and,  when  these  are  divided  carefully  npon  the  director,  the  right  carotid 
will  be  seen  near  the  center  of  the  wound.  Following  this  down,  the 
arteria  innominata  will  be  found  just  behind  the  sterno-clavicular  articu- 
lation (Fig.  279).  Being  exposed  with  the  scalpel-handle,  or  any  dry  dis- 
sector not  likely  to  wound  the  vessel,  the  aneurism-needle  should  be  passed 
from  right  to  left  behind  the  artery,  care  being  taken  to  avoid  wounding 
the  right  vena  innominata  and  the  pneumogastric  nerve,  or  puncturing 
the  pleura,  in  which  the  artery  is  partly  imbedded.  It  is  well  to  bear  in 
mind  that  the  left  innominate  vein  crosses  this  artery,  although  usually 
very  low  down.  When  the  aorta  is  situated  low  in  the  thorax,  it  may  be 
necessary  to  remove  the  sternal  end  of  the  clavicle  and  a  segment  of  the 
sternum,  as  was  done  by  Cooper,  of  San  Francisco,  in  two  instances. 

An  element  of  danger  in  this  operation  is  the  origin  of  an  abnormal 
branch  from  the  innominate.  In  the  cases  of  Lizars  and  V.  Mott  this 
anomaly  existed,  and  death  was  caused  by  hemorrhage  at  the  seat  of 
the  ligature.  In  thirty-four  consecutive  subjects  which  I  examined  as  to 
this  feature,  I  found  an  abnonnal  branch  to  be  derived  from  the  innomi- 
nate in  five.  When  the  necessity  for  occlusion  of  the  arteria  innominata 
arises,  and  the  conditions  are  such  as  to  permit  it,  the  following  method 
should  be  followed :  The  right  common  carotid  should  first  be  tied,  one 
inch  above  its  origin.  By  a  careful  dissection  the  first  division  of  the 
subclavian  and  its  branches  should  then  be  exposed,  drawing  the  internal 
jugular  to  the  outer  side  untU  the  vertebral  is  secured.  Avoiding  the 
phrenic  nerve,  as  it  descends  to  the  inner  side  of  the  scalenus  anticus,  the 
internal  mammary  and  branches  of  the  thyroid  axis  should  be  secured, 
and  finally  a  ligature  of  large,  smooth  catgut,  or  prepared  nerve  placed 
around  the  subclavian  artery,  about  the  middle  of  its  first  portion.  A 
careful  study  of  the  anatomy  and  surgery  of  this  region  leads  me  to  con- 
clude that  this  procedure,  though  difficult  of  execution,  offers  a  better 
prospect  of  success  than  deligation  of  the  larger  and  primitive  trunk, 
nearer  the  heart. 

In  the  operation  and  after-treatment  of  the  wound  the  most  careful 
antisepsis  should  be  practiced,  and  perfect  drainage  maintained. 

Ligation  of  the  Common  Carotid  Arteries  and  the  Internal  Jugular 
Vein — Anatomy. — In  one  hundred  and  twenty  dissections  I  found  the 
common  carotid  artery  to  bifurcate  on  a  level  with  the  notch  between  the 
two  alse  of  the  thyroid  cartilage  in  one  hundred  and  sixteen.  The  anoma- 
lies of  this  vessel  are  so  rare  that  they  do  not  deserve  mention  in  this  work. 

Operation. — A  firm  cushion  should  be  placed  under  the  shoulders  and 
lower  part  of  the  neck,  with  the  chin  elevated,  and  the  face  turned  in 
the  direction  away  from  the  side  upon  which  the  operation  is  to  be  per- 
formed. A  line  extending  from  the  tragus  of  the  ear  to  the  sterno-cla- 
vicular articulation  will  cover,  and  be  parallel  with,  the  internal  and 
common  carotid  arteries  in  their  surgical  length.  This  line  wdl  strike 
the  center  of  bifurcation  of  the  primitive  carotid  almost  invariably  on  a 
level  with  the  upper  border  of  the  thyroid  cartilage,  and  the  anterior  edge 
of  the  sterno-mastoideus  from  one  inch  and  a  quarter  to  one  and  a  half 


238 


A  TEXT-BOOK   ON  SURGERY. 


below  this  level.  The  point  of  election  is  about  one  inch  below  this 
bifurcation,  and  at  the  upper  border  of  the  anterior  belly  of  the  omo- 
hyoid muscle. 


Fia.  280.— Showing  lines  of  incision  and  relation  of  parts  iuvuh\:U  iu  delineation  of  the  common  carotid, 
above  and  below  the  anterior  belly  of  the  omo-hyoid,  and  the  external  carotid  below  the  lingual  and 
above  the  facial. 


The  incision,  being  made  with  its  direction  as  above  given,  its  center 
about  one  inch  below  the  bifurcation,  extending  from  one-and-a-half  to 
two  inches  above  and  below  this  point,  will  divide  first  the  integument. 


LIGATION   OF  ARTERIES.  239 

and  witt  this  the  thin  plafysma  myoides,  some  filaments  of  the  super- 
ficialis  colli  nerve,  of  no  importance,  and  some  small  veins  passing  from 
the  anterior,  either  to  the  internal  or  external  jugular  veins.  About 
the  center  of  the  wound  the  edge  of  the  mastoideus  will  be  seen,  and 
belovr  this  (usually)  the  anterior  belly  of  the  omo-hyoideus  (B^ig.  280, 
lower  half).  The  sheath  of  the  carotid  and  jugular  vein  is  now  exposed, 
often  crossed  by  the  thyroid  veins,  and  the  cervicalis  descendens  artery, 
the  descendens  noni  nerve  almost  invariably  lying  upon  the  center  of  the 
sheath,  being  parallel  with  the  axis  of  the  common  and  internal  carotids. 
In  two  instances  I  have  seen  the  superior  thyroid  artery  turn  directly 
down,  in  front  of  the  common  trunk,  for  an  inch  or  more,  and  then  turn 
abruptly  inward  to  be  distiibuted  to  the  thyroid  body.  Under  such  ab- 
normal conditions  this  vessel  would  probably  be  divided.  The  communi- 
cans  noni  is  occasionally  found  crossing  the  sheath  from  without  inward, 
to  anastomose  with  the  descendens.  These  nerves  will  be  drawn  to  the 
outer  or  inner  side  of  the  wound,  as  is  most  convenient.  The  sheath 
should  be  opened  on  its  tracheal  side,  as  far  as  possible  from  the  jugu- 
lar vein,  and  the  needle  passed  from  without  inward,  being  kept  close  to 
the  artery  in  order  to  avoid  wounding  the  vein  or  including  the  pneumo- 
gastric  or  sympathetic  nerves.  The  sheath  should  be  well  opened,  and 
the  artery  clearly  exposed,  so  that  the  needle  may  be  manipulated  with 
more  of  certainty  and  less  danger  from  these  too  common  and  unfortu- 
nate accidents.  In  several  instances  the  artery  has  been  transfixed  ;  the 
jugular  has  been  wounded  ;  the  pneumogastric  or  sympathetic  nerves 
included  in  the  ligature,  for  want  of  precision  in  separating  the  artery 
from  the  vein.  Certainly  the  danger  of  slough  in  the  artery  is  not  so 
great  as  the  dangers  above  enumerated.  Just  as  the  needle  is  being  in- 
troduced, pressure  above  upon  the  vein  would  empty  it  of  blood,  and  of 
course  diminish  the  danger  of  wounding  it. 

The  operation  of  tying  the  carotid,  just  below  or  behind  the  omohyoid, 
is  practically  the  same  as  that  just  described  (Fig.  280). 

In  order  to  secure  this  vessel  at  the  root  of  the  neck,  an  incision  should 
be  made  in  the  carotid  line,  extending  from  the  sterno-clavicular  articu- 
lation upward  a  distance  of  three  or  four  inches,  and  between  the  two 
heads  of  origin  of  the  sterno-mastoid  muscle.  This  will  divide  the  integu- 
ment, superficial  fascia,  platysma,  and  deejj  fascia,  and  some  descending 
superficial  nerves.  The  fibers  of  the  sterno-mastoid  may  be  separated 
and  held  to  either  side  by  retractors.  Immediately  beneath  it  vrill  be 
found  the  anterior  jugular  vein,  and  some  small  branches  emptying  into 
it.  If  not  easily  displaced,  they  should  be  secured  with  a  double  liga- 
ture, and  divided  between  the  threads.  The  fibers  of  the  sterno-hyoid  or 
stemo-thyroid  muscles  should  next  be  divided  on  a  grooved  director, 
and  turned  aside  or  separated  in  the  line  of  the  artery.  The  vessel  will 
be  seen  deeply  situated  in  the  line  already  given.  The  ligature  should 
be  passed  from  the  outer  side.  Or  an  L-shaped  incision,  similar  to  that 
made  for  deligation  of  the  innominate  (Fig.  279),  may  be  made,  and 
the  carotid  found  by  separating  the  sternal  tendon  of  the  mastoideus 
muscle  and  turning  this  outward.     For  the  left  carotid  see  Fig.  281. 


240 


A  TEXT-BOOK  ON  SURGERY. 


The  approacli  to  the  vessel  in  this  region  should  be  very  cautious,  espe- 
cially upon  the  left  side  of  the  neck,  since  the  internal  jugular  vein 
crosses  from  the  outer  to  the  inner  side  by  the  front.     On  the  right  side 


Fig.  281.— Showing  the  relations  of  parts  involved  in  deligation  of  the  left  carotid,  at  the  root  of  the  neck, 
and  tlie  left  suhclavian  in  its  first  surgical  division. 

the  vein  is  a  little  more  external.  The  pneumogastric  nerve  lies  behind 
and  to  the  outer  side  of  the  artery,  while  the  inferior  thyroid  artery  and 
sympathetic  nerve  are  more  deeply  situated.      The  aneurism -needle 


LIGATION   OF  ARTERIES. 


241 


Fio.  282.— Showing  the  relations  of  the  important  organs  at  the  root  of  the  neck  and  apex  of  the  thorax. 
Frozen  horizontal  section  at  the  level  of  the  third  dorsal  vertebra.  (After  Braune.)  1,  Innominate. 
2,  Left  carotid.  3,  Left  subclavian.  4,  Right  subclavian  arteries.  6,  6,  Left  and  right  innominate 
veins.  7  and  8,  Subclavian  veins.  9,  Inferior  thyroid' vein.  10,  Trachea.  11^  OJsophagus.  12, 
Spinous  process  of  second  dorsal  vertebra,     a  a,  Pneumogastric  nerves,     b,  Phrenic  nerves. 


242 


A  TEXT-BOOK  ON  SURGERY. 


should  be  passed  around  the  artery,  from  the  outer  toward  the  inner 
side. 

In  the  "  Prize  Essay  "  of  the  American  Medical  Association  for  1878  I 
collected  histories  of  789  cases  in  which  the  common  carotid  artery  had 
been  tied  for  all  causes,  of  which  323,  or  41  per  cent,  died.  An  analysis 
of  these  cases  is  impossible  here.  I  do  not  believe  that  the  death-rate 
will  ever  again  reach  this  alarming  figure.  The  introduction  of  animal 
ligatures  and  antisepsis  have  already  greatly  diminished  the  death-rate 
in  operations  upon  the  arteries. 


Fig.  283. — Horizontal  section  at  the  level  of  the  seventh  cervical  vertebra.  1, 1,  The  right  and  left  com- 
mon carotid  arteries  and  the  internal  jui^ular  veins.  2,  The  right  and  left  vertebral  arteries  and  veins. 
Directly  between  the  vertebral  and  carotid  arteries  is  seen  the  sympathetic  nerve  and  the  inferior 
thyroid  artery  and  some  of  its  branches.  The  pneumogastric  nerves  are  seen  between  and  slightly 
posterior  to  the  internal  jugular  veins  and  the  common  carotids.  3,  Trachea.  4,  QSsophagus.  5, 
Transversalis  colli  artery  and  veins  and  descending  branches  of  the  subclavian  artery.  6,  Cords  ol 
brachial  ple.Kus.    7,  7,  External  jugular  vein.     (After  Braune.) 

Thirty-four  cases  are  on  record  in  which  both  trunks  were  tied,  of 
which  twenty-five  recovered.* 

Ligation  of  the  Internal  Carotid  Artery — Anatomy. — This  vessel  is 
a  direct  continuation  of  the  common  trunk,  and,  while  straight  in  its 
lower  portion,  it  becomes  slightly  tortuous  as  it  approaches  the  carotid 
canal.  An  abnormal  branch  was  found  to  be  derived  from  its  first  portion 
in  seven  of  one  hundred  and  twenty  dissections. 

Operation. — The  position  is  the  same  as  for  tying  the  common  trunk. 


Op.  cit.     See  also  Riegner's  case,  "  Centralblatt  fur  Chirurgie,"  No.  26,  1884. 


LIGATION   OF   ARTERIES. 


243 


The  incision  should  be  made  in  the  carotid  line,  with  its  center  from  one 
half  to  three  quarters  of  an  inch  above  the  upper  border  of  the  thyroid 
cartilage.  The  same  structures  will  be  divided  superficially,  and  the 
veins  will  be  seen  superficial  to  the  artery.    As  shown  in  C,  Fig.  285,  they 


-The  usual  relation  of  the  contents  of  the  surgical  triangles  of  the  neck.      Frc 
dissections. 


may  cross  the  internal  carotid  almost  at  a  right  angle,  or  (as  in  A  or  B) 
they  may  empty  into  a  single  trunk,  and  run  parallel  with  the  external 
carotid.  This  last  is  the  most  usual  way,  but  it  will  be  scarcely  possible 
to  ligate  the  internal  carotid  without  ligature  and  division  of  some  of 


244 


A   TEXT-BOOK   ON   SURGERY. 


these  veins.  The  descendens-noni  nerve  will  be  seen  running  along  the 
artery,  the  Tiypoglossal  crossing  it  about  one  inch  from  the  bifurca- 
tion.    The  vessel  being  exposed,  the  needle  is  introduced  on  the  oufr^ 


Fig.  285. — Eelation  of  the  veins  to  the  carotids.     (Life  size.) 

er  side,  avoiding  the  jugular  vein  and  pneumogastric  nerve  exter- 
nally, the  external  carotid  internally,  and  the  hypoglossal  nerve  su- 
perficially. The  pharyngea  ascendens  is  in  intimate  relation  to  the 
internal  carotid,  running  parallel  with  it  on  its  inner  aspect.  Occa- 
sionally the  first  cervical  ganglion  of  the  sympathetic  extends  as  low 
as  this  point.  It  will  be  avoided  by  keeping  the  needle  close  to  the 
artery. 

The  internal  carotid  artery  has  been  tied  nineteen  times,  with  twelve 
recoveries.*  In  six  of  the  fatal  cases  the  common  trunk  had  been  pre- 
viously and  ineffectually  secured,  and  in  the  remaining  case  I  tied  the 
common,  external,  and  internal  carotids,  in  removing  an  immense  tumor 
which  involved  these  vessels.  The  patient  died  from  shock  in  eighteen 
hours. 

Ligation  of  the  External  Carotid  Artery. — From  the  extensive  dis- 
tribution of  its  branches  to  the  exposed  portions  of  the  neck  and  face, 
the  external  carotid  artery  demands  a  more  careful  consideration  than 
any  single  vessel  of  the  human  body. 


Op.  cit. 


LIGATION   OF  ARTERIES. 


245 


I 


Anatomy. — Leaving  the  common  trunk  at  the  iipper  border  of  the 
thyroids  cartilage,  well  forward  of  the  anterior  border  of  the  sterno- 
mastoid  muscle,  this  vessel  arches  forward  and  upward  (its  concavity 
looking  toward  the  lobule  of  the  ear)  until,  on  an  average  of  "92  inch 
above  the  bifurcation,  after  giving  off  the  facial  branch,  it  turns  ob- 
liquely upward  and  backward  to  a  point  opposite  the  insertion  of  the 
external  pterygoid  muscle  into  the  neck  of  the  condyle  of  the  lower 
jaw,  where  it  terminates  by  dividing  into  the  temporal  and  internal 
maxillary  arteries. 

Eight  regular  branches  belong  to  this  vessel  (though  some  anatomists, 
among  whom  are  Hyrtl,  Wilson,  and  Richardson,  describe  nine).  On 
its  anterior  aspect  arise  from  below,  upward,  the  thyroidea  superior, 
Ungualis,  maxillaris  externa,  and  maxillaris  interna.  On  its  poste- 
rior and  internal  aspect  the  pharyngea  ascendens,  and  posteriorly  the 
occipitalis,  auriciilaris,  and  temporalis. 


Posterior  temporal 


Anterior  temporal. 

- Transverse  facial. 

---  Internal  maxillary. 

"2.  93X 

Parotid  brcuchea, 

■  Ascending  palatine, 

i.sa^'^. 

Tonsillar. 


Pio.  286. — The  external  carotid  and  its  branches.     The  average  an'angement  of  one  hundred  and  twenty-one 
dissections  by  the  author.     (Life  size.) 

The  usual  arrangement  of  these  branches  is  seen  in  Fig.  286,  which 
is  the  average  of  one  hundred  and  twenty-one  dissections.  Abnor- 
mal deviations  from  this  relation  of  the  branches  to  the  parent  trunk 


246 


A  TEXT-BOOK   ON   SURGERY. 


occur  occasionally,  and  types  of  these  may  be  seen  in  Figs.  287 
and  288.  The  relations  of  the  veins  to  these  arteries  are  shown  in 
Fig.  285. 

Operation. — The  external  carotid  may  be  tied  in  the  majority  of  cases 
at  two  points,  viz.,  between  the  origins  of  the  fhyroidea  superior  and 
lingualis,  about  one  quarter  of  an  inch  above  the  septum  of  bifurcation 
(see  Fig.  286),  or  between  the  origins  of  the  maxillaris  externa  and  auri- 
cularis,  about  one  inch  and  a  half  above  the  thyroid  cartilage.  At  the 
lower  point  of  election  the  operation  is  the  same  as  for  ligature  of  the 
internal  carotid  on  the  same  plane,  except  that  the  external  carotid  is 
usually  from  one  quarter  to  one  half  inch  nearer  the  median  line  than  the 
internal. 

Notwithstanding  that  the  analysis  of  one  hundred  and  twenty-one 
consecutive  dissections  has  convinced  me  of  the  propriety  of  ligaturing 


Fig.  287. — Unusual  arrangement  of  the  branches  of  the  external  carotid.  1,  The  lingual  and  facial  from  b 
common  origin.  2,  The  lingual  and  facial  superior  thyroid  from  a  common  origin.  3,  Close  relation  of 
first  five  branches  to  each  other. 


this  vessel,  and  that  the  history  of  the  cases  in  which  it  has  been  tied 
shows  a  rate  of  mortality  far  below  that  of  ligature  of  the  common  carotid, 
yet  the  proximity  of  large  and  important  branches  to  each  other,  or  to 
the  bifurcation  of  the  commion  carotid  in  many  instances,  makes  it  of  the 
utmost  importance  that  the  surgeon  should  jsroceed  with  great  care  and 
discretion.     The  wound  should  be  thoroughly  cleansed,  and  the  vessel 


LIGATION  OF  ARTERIES. 


247 


examined  mth  scrupulous  care  above  and  below  the  ligature,  and  any 
collateral  brancli  or  branches  within  less  than  one  quarter  of  an  inch 
should  be  also  secured. 

Should  the  artery  be  found  to  be  normal  (as  in  Fig.  286),  I  would 
place  the  ligature  nearer  the  Ungualis  than  the  bifurcation,  and  tie  this 
vessel  separately.  If  (as  in  Fig.  287,  3)  a  rare  form  should  exist,  I 
would  ligature  close  to  these  branches,  and  tie  each  of  them  in  its  turn. 
This  same  conservative  rule  must  apply  to  every  case. 

The  operation  at  or  above  the  posterior  belly  of  the  digastric  is  com- 
paratively safer,  and  is  applicable  to  all  lesions  above  this  point.  The 
incision  should  extend  from  the  lobule  of  the  ear  along  the  ramus  of  the 
Jaw,  down  to  the  level  of  the  thyroid  cartilage.  Cutting  through  the 
superficial  structures,  the  artery  will  be  found  just  behind  the  posterior 
belly  of  the  digastric  muscle. 

Above  this  level — that  is,  after  the  artery 
enters  the  parotid  gland — it  is  so  situated  that 
it  should  not  be  cut  down  upon.  The  incision 
would  involve  the  facial  nerve,  causing  paral- 
ysis of  the  muscles  of  expression.  In  malig- 
nant disease  of  the  parotid,  where  this  gland 
is  removed,  the  vessel  may  as  well  be  secured 
here  as  not,  since  the  operation  itself  usually 
destroys  the  facial  nerve. 

It  is  a  remarkable  fact  that,  notwithstanding 
the  close  proximity  of  the  branches  of  the  ca- 
rotid, in  a  number  of  instances  in  which  it  has 
been  ligatured  without  the  precaution  of  secur- 
ing immediate  collateral  branches,  there  has  not 
followed  secondary  haemorrhage.  No  explana- 
tion of  this  fact  has  appeared  so  definite  as  the 
one  given  by  Prof.  H.  B.  Sands,  "which  takes 
into  account  the  remarkable  reparative  power 
of  the  tissues  surrounding  this  vessel.  Suppu- 
ration is  extremely  rare,  the  wounded  tissues 
soon  become  consolidated  by  plastic  material, 
and  secondary  hsemoiThage  is  prevented  by 
changes  occurring  outside  of,  as  much  as  by 
changes  taking  place  loitMn,  the  vessel  liga- 
tured." 

On  account  of  the  importance  of  maintaining 
the  integrity  of  the  circulation  to  the  brain, 
ligation  of  the  common  carotid,  for  a  lesion  in 
the  distribution  of  the  external  carotid,  should 
never  be  performed  when  a  sufficient  distance 

remains  between  the  lesion  and  the  bifurcation  of  the  common  trunk  to 
allow  of  the  application  of  the  ligature.  I  have  the  histoi-ies  of  ninety- 
three  cases  of  ligature  of  the  external  carotid,  in  sixty-nine  of  which  this 
vessel  alone  was  tied.     Of  these  sixty-nine  cases  only  three  died,  while 


Fig.  288. — An  enlarged  superior 
thyroid  artery. 


248  A  TEXT-BOOK  ON  SURGERY. 

the  death-rate  after  ligature  of  the  common  trunk,  for  the  same  period, 
was  41  per  cent. 

Ligation  of  the  Bwperior  Thyroid  Artery — Anatomy. — This  branch 
was  present  in  every  instance  in  one  hundred  and  twenty-one  dissec- 
tions. It  originated  almost  invariably  on  a  level  with  the  thyroid 
notch.  In  one  of  twenty-five  cases  it  will  be  found  to  have  a  com- 
mon origin  with  the  lingual,  or  the  lingual  and  facial.  See  Fig. 
287,  1,  2. 

Oioeration. — With  the  neck  in  the  surgical  position,  i.  e.,  with  the 
head  thrown  back  and  the  face  turned  to  the  opposite  side,  make  an  in- 
cision two  inches  long,  parallel  with,  and  one  fourth  of  an  inch  in  front 
of,  the  carotid  line.  The  center  of  this  incision  must  be  on  a  level  with 
the  thyroid  notch.  Immediately  beneath  the  skin  ^y^^jplatysma  myoides 
will  be  seen  the  thyroid,  lingual,  hyoid,  and  other  veins,  which  may 
assume  either  of  the  forms  or  relations  shown  in  Fig.  285,  A,  B,  being 
most  common.  These  being  tied  and  divided,  the  artery  will  be  found 
opposite  the  point  above  indicated. 

The  thyro-hyoid  nerve  will  occasionally  be  seen  passing  across  this 
artery,  although  usually  nearer  the  median  line.  The  external  laryngeal 
passes  beneath  it. 

Ligation  of  the  Lingual  Artery — Anatomy. — From  its  origin,  usu- 
ally opposite  the  cornu  of  the  hyoid  bone,  it  ascends  obliquely  upward 
and  inward,  and  is  superficial  until  it  passes  underneath  the  stylo- 
hyoideus  and  digastricus  (posterior  belly),  and  then  more  deeply  behind 
the  hyo-glossus. 

In  two  of  one  hundred  and  twenty-one  cases  it  originated  in  common 
with  the  superior  thyroid,  and  in  two  other  instances  with  this  vessel  and 
the  facial.  In  thirty-one  of  one  hundred  and  twenty- one  cases  it  arose 
from  a  trunk  common  to  it  and  the  facial,  being  abnormally  associated  in 
one  in  every  three  and  a  half  dissections. 

Operation. — The  lingual  artery  may  be  secured  either  below  the 
digastric  or  above  this  point,  where  it  passes  beneath  the  hyo-glossus. 

For  the  low  operation  make  an  incision  as  in  the  case  of  the  superior 
thyroid,  except  that  its  center  should  be  opposite  the  os  hyoides.  The 
artery  will  be  found  in  the  lingual  triangle,  bounded  posteriorly  by  the 
eceternal  carotid,  above  by  the  digastric  muscle,  below  by  the  os  hyoides. 
The  middle  constrictor  muscle  is  behind  it ;  the  platysma  myoides  in 
front,  and  under  this  the  veins  above  noted.  The  hypoglossal  nerve  is 
usually  just  above  it  as  it  crosses  the  carotid,  while  the  thyro-hyoid 
branch  of  this  nerve  crosses  the  artery  on  its  way  to  the  miiscle  it 
supplies. 

The  high  operation  is  one  of  considerable  difficulty.  The  face  should 
be  well  turned  to  the  opposite  side,  the  chin  elevated,  and  held  per- 
fectly immovable.  Beginning  immediately  over  the  os  hyoides,  near  the 
median  line  of  the  neck,  an  incision  is  made  outward,  and  parallel  with 
this  bone  as  far  as  the  great  cornu,  where  it  is  curved  upward  to  the 
angle  of  the  jaw  (Fig.  289).  This  crescentic  flap  is  turned  up,  and  with 
it  the  sub-maxillary  gland,  in  a  groove  on  the  under  surface  of  which 


LIGATION    OF   ARTERIES. 


249 


the  facial  artery  runs.     As  soon  as  the  hyoid  bone  is  exposed  it  should 
be  fixed  with  a  tenaculum  and  drawn   steadily  down.      The  posterior 


m'" 


«7 


Fig.  289. — Ligation  of  the  right  subclavian  in  its  third  surgical  division ;  the  facial  in  the  neck  and  the 
lingual  beneath  the  hyo-glossus  muscle. 


belly  of  the  digastric  will  now  be   seen  passing  obliquely  downward 
and  forward  to  the  central  tendon  in  the  hyoid  bone.     Passing  beneath 
this  muscle,  and  superficial  to  the  hyo-glossus,  is  seen  the  hypoglos- 
17 


250  A  TEXT-BOOK   ON  SURGERY. 

sal  nerve,  which  runs  parallel  with  and  above  the  artery.  Depress  the 
posterior  belly  of  the  digastric,  insert  a  director  beneath  the  posterior 
fibers  of  the  hyo-glossus,  and  divide  these.  The  artery  will  be  found 
just  beneath  this  muscle,  resting  upon  the  middle  constrictor  of  the 
pharynx. 

The  ligation  of  this  artery  is  frequently  practiced  preliminary  to  ex- 
cision of  the  tongue  for  malignant  disease,  and  occasionally  to  arrest 
haemorrhage. 

Ligation  of  the  Facial  Artery — Anatomy.— The  facial  artery  was 
present  in  one  hundred  and  twenty  of  one  hundred  and  twenty-one  dis- 
sections. In  the  instance  in  which  it  was  missing  its  facial  distribution 
was  taken  by  the  transverse  facial  from  the  temporal,  and  its  cervical 
by  branches  from  the  Ungual  and  the  external  carotid.  Its  origin  is 
usually  about  one  fourth  of  an  inch  above  the  lingual.  It  is  the  long- 
est branch  of  the  external  carotid.  In  thirty-one  of  one  hundred  and 
twenty  cases  it  arose  in  common  with  the  lingual,  and  in  two  in- 
stances it  was  from  a  trunk  in  common  with  this  artery  and  the  supe- 
rior thyroid. 

Operation. — In  its  cervical  distribution  this  vessel  will  require  to  be 
tied  at  or  near  its  origin  from  the  carotid.  The  incision  along  the  axis 
of  the  carotid,  as  given  before,  with  its  center  a  quarter  of  an  inch  above 
the  hyoid  bone,  will  lead  to  the  facial.  The  posterior  belly  of  the  digas- 
tricus  wiU  be  found  with  its  center  usually  above  the  origin,  but  soon 
crossing  the  artery.  The  ninth  nerve  is  just  below.  For  lesion  of  this 
vessel  in  the  face  it  can  be  readily  secured  as  it  crosses  the  inferior 
maxilla  in  the  depression  at  the  anterior  border  of  the  masseter  (Fig. 
290).  Before  making  the  incision,  which  should  be  parallel  with  the 
horizontal  j)ortion  of  the  inferior  maxilla,  the  skin  should  be  well 
pulled  up  from  the  neck,  so  that,  after  healing,  the  cicatrix  will  fall  be- 
low the  jaw. 

Ligation  of  the  Ascending  Pharyngeal — Anatomy. — This  artery 
was  derived  from  the  external  carotid  in  one  hundred  and  eleven 
of  one  hundred  and  twenty- one  cases,  and  from  the  internal  ca- 
rotid in  four  others.  It  usually  comes  off  at  a  point  opposite  the 
origin  of  the  lingual,  and  occasionally  from  the  bifurcation  of  the 
primitive  carotid.  A  pharyngeal  branch  is  not  uncommon  from  the 
occipital. 

Operation. — The  external  carotid  must  be  exposed  by  an  incision  the 
center  of  which  is  oj^posite  the  level  of  the  hyoid  bone.  The  vessel  wUl 
be  seen  ascending  between,  and  parallel  with,  the  external  and  internal 
carotids. 

One  fatal  case  is  recorded  from  haemorrhage  after  a  wound  of  the 
ascending  pharyngeal. 

Ligation  of  the  Occipital  Artery — Anatomy. — The  occipital  was 
present  in  one  hundred  and  twenty  of  one  hundred  and  twenty-one  dis- 
sections, and  it  was  found  to  be  opposite  the  facial  in  the  majority  of 
cases.  In  the  subject  in  which  it  was  missing,  a  large  branch  from  the 
inferior  thyroid  (not  the  ascending  cervical)  took  its  distribution.     Not 


LIGATION    OF   ARTERIES. 


251 


infrequently  the  posterior  auricular  or  a  pharyngeal  brancli  arose  from 
this  vessel. 

Operation. — It  may  be  secm-ed  near  its  origin,  or  behind  the  mastoid 
process.  For  the  low  operation,  make  an  incision  in  the  carotid  line,  the 
center  of  which  is  about  one  inch  above  the  thyroid  notch.     After  divid- 


FiG.  290. — Ligation  of  the  posterior  tc-mporu'i  at  the 


11.1  of  the  facial  upon  the  inferior  maxilla. 


ing  the  deep  fascia  the  hypoglossal  nerve  will  be  seen,  which,  if  followed 
backward,  will  lead  unerringly  to  the  artery,  underneath  which  it  winds. 
The  posterior  belly  of  the  digastric  muscle  will  usually  require  to  be 
lifted  upward. 

Behind  the  mastoid  the  occipital  may  be  tied  where  it  passes  beneath 


252 


A  TEXT-BOOK  ON  SURGERY. 


tlie  cranial  attachment  of  the  sterno-mastoid  muscle  (Pig.  291).  From 
one  half  to  three  fourths  of  an  inch  behind  the  mastoid  process  an  in- 
cision about  two  inches  long  should  be  made,  extending  upward  and 
backward.  The  aponeurosis  of  the  sterno-mastoid  muscle  is  divided  on 
a  director,  and  the  artery  exposed.     The  constant  relation  of  this  vessel 


-^^ 


Fio.  291.— Ligation  M'  the  ordpital  behind  the  inru 
also  Bhowiutr  the  relations  of  the  facial  ner\ 


oid  \>un  I  ^^  and  the  .  Miuinon  temporal  near  the  zygoma, 
:  to  the  teiminal  portion  of  the  external  cai'Otid. 


to  the  groove  on  the  under  surface  of  the  mastoid  process  will  serve  as  a 
valuable  guide. 

The  common  carotid  has  been  tied  in  several  instances  for  lesions  of 
the  occipital.     This  should  never  be  done. 

Ligation  of  the  Posterior  Auricular — Anatomy. — In  eleven  of  one 
hundred  and  twenty-one  dissections  this  vessel  arose  from  the  occipital, 
and  in  four  it  was  absent.  Its  origin  is  usually  one  inch  and  four  fifths 
above  the  thyroid  notch. 


LIGATION   OF   ARTERIES.  253 

For  anatomical  reasons,  in  lesions  of  this  artery  the  external  ca- 
rotid should  be  tied,  Just  above  the  posterior  belly  of  the  digastric, 
between  its  origin  and  that  of  the  occipital.  It  runs  under  the  pa- 
rotid gland,  is  crossed  by  the  facial  nerve,  and  has  beneath  it  the  spinal 
accessory. 

Ligation  of  the  Temporal  and  Internal  Maxillary  Arteries — Anat- 
omy.— The  temporal  and  internal  maxillary  arteries  begin  at  the  termi- 
nal bifurcation  of  the  external  carotid,  in  the  substance  of  the  parotid 
gland,  at  an  average  distance  of  two  inches  and  nine  tenths  from  the 
thyroid  notch. 

Operation. — The  temporal  artery  may  be  secured  by  a  perpendicu- 
lar incision  immediately  in  front  of  the  tragus  of  the  ear,  where  it  crosses 
the  zygoma  superficially  (Fig.  291).  For  lesions  of  this  vessel  above  the 
temporal  fossa,  and  often  in  wounds  in  this  region,  the  ligature  will 
be  unnecessary,  since  direct  compression,  by  means  of  the  knotted 
bandage,  will  suffice.  When  either  this  artery  or  the  internal  maxil- 
lary are  wounded  in  the  substance  of  the  parotid  gland,  the  external  ca- 
rotid should  be  tied  at  the  posterior  belly  of  the  digastric.  The  same 
procedure  is  indicated  in  lesions  of  the  internal  maxillary,  in  its  deep- 
er portions. 

Ligation  of  the  Internal  Jugular  Vein. — The  intimate  relation  of  this 
vein  to  the  internal  and  common  carotid  arteries  renders  it  accessible  by 
the  same  incisions  laid  down  for  the  ligation  of  the  arteries.  The  vein 
is  contiguous  to  the  artery,  and  is  external  and  slightly  superficial  to  it. 
On  the  left  side,  at  the  root  of  the  neck,  the  jugular  comes  more  to  the 
front,  while  on  the  right  side  it  tends  to  the  outer  side. 

The  rules  which  apply  to  the  ligation  of  arteries  apply  with  equal 
force  to  the  ligation  of  veins.  The  jugulars  should  be  encircled  with  an 
animal  ligature,  not  tied  with  a  lateral  loop,  as  has  been  practiced.  The 
aneurism-needle  should  be  passed  from  the  inner  side.* 

The  anterior,  external,  and  posterior  jugular,  and  other  veins  of  the 
neck,  do  not  demand  especial  consideration.  When,  in  operations  in  the 
neck,  it  becomes  necessary  to  divide  them,  a  double  catgut  should  be 
applied,  and  the  vessel  divided  between  the  two  ligatures. 

The  Subclavian  Arteries  and  their  Branches — Anatomy. — The  right 
subclavian,  larger,  shorter,  and  more  superficial  at  its  origin  than  the 
left,  is  derived  from  the  innominate  behind  the  origin  of  the  carotid, 
about  the  level  of  the  upper  margin  of  the  clavicle  (more  frequently  above 
than  below  this  line),  behind  the  interval  between  the  two  tendons  of  the 
sterno-mastoideus .  It  is  the  direct  continuation  backward,  upward,  and 
outward  of  the  arch  of  the  innominate,  and  is  continuous  with  the  axil- 
lary artery,  at  the  lower  edge  of  the  first  rib.  Its  average  length  is  2  "83 
inches. 

The  left  subclavian,  derived  1  "23  inch  beyond,  to  the  left  of,  and  more 
deeply  situated  in  the  thorax  than,  the  innominate,  travels  almost  verti- 

*  See  Prof.  S.  W.  Gross's  admirable  article  in  "  American  Journal  of  the  Medical  Sci- 
ences," 1867. 


254 


A  TEXT-BOOK   ON   SURGERY, 


cally  upward,  until  it  mounts  above  tlie  upper  surface  of  the  first  rib, 
wlien  it  curves  very  abruptly  outward  and  downward,  passing  behind  the 
scalenus  anticus  and  thence  to  the  lower  edge  of  the  first  rib.  Its  length, 
in  the  average,  is  3 '74  inches. 

Each  subclavian  has  three  surgical  divisions.     The  first  division  of 
the  right  artery  is  from  its  origin  from  the  innominate  to  the  inner  bor 


Oerviealis 
ascendens. 

Thyroidea  | 
interior.  \ 

Transversa- 
lis  colli. 

Scapularis 
posterior. 

Saprascapu- 1  _____ 

laris.  S  -■^mm''        ,v'a.| 

Intercostalis 

superior. 

Mammaria 

interna. 


Tnns  coL 
Profunda 


\Arteriae  Cononariae 


Fig.  292.— Eelation  of  the  great  vessels  to  each  other  at  their  origins  from  the  arch  of  the  aorta,  and  the  rela- 
tion of  tne  branches  of  the  subclavian  arteries  to  each  other.     From  the  author's  dissections. 


der  of  the  scalenus  anticus.  That  of  the  left  artery,  from  its  origin  at 
the  arch  of  the  aorta  to  the  inner  border  of  the  left  scalenus  anticus 
(Fig.  292). 

The  second  and  third  portions  of  both  vessels  are  identical  as  re- 
gards direction  and  relation,  being  different  in  the  origins  of  their 
respective  branches.  The  second  surgical  division  of  each  is  entire- 
ly to  the  inner  side  of  the  inner  border  of  the  first  rib.  The  third 
portion  rests  chiefly  on  the  upper  surface  of  the  first  rib,  and  extends 
from  the  outer  border  of  the  scalenus  anticus  to  the  lower  border  of 
this  rib. 

The  first  portion  of  the  right  subclavian  varies  from  three  fourths  to 
one  inch  and  a  half  in  length,  the  average  length  being  1'15  inch. 

The  first  portion  of  the  left  artery  varies  from  one  inch  and  a  half  to 
three  inches,  the  average  length  being  2 '06  inches. 


LIGATION   OF   AETERIES. 


255 


Trans  verse  Cervical 


The  second  portion  of  the  riglit  subclavian  averaged  08  incli,  the 
same  division  of  the  left  subclavian  being  "56  inch  in  length. 

The  third  portion  of  the  rigJit  artery  is  a  little  less  ;  the  same  division 
of  the  left  subclatian  a  little  more  than  I'll  inch  in  length. 

!Xine  important  branches  arise  directly  or  indirectly  fi-om  the  subclor- 
tian  arteries :  the  vertebral,  internal  ma/nimary,  transversalis  colli, 
suprascapular,  inferior  thyroid,  cervicalis  o^scendens,  superior  inter- 
costal, profunda  cervicis,  and  posterior  scapular. 

The  right  vertebral,  the  branch  most  constant  in  origin,  arises  from 
the  superior  and  posterior  aspect  of  the  main  trunk  (Fig.  293)  and  passes 
upward  to  the  verte- 
bral foramen,  in  the  Ascend, ngCerv/calS 
sixth  cervical  verte- 
bra ;  at  times  to  the 
"fifth ;  less  frequently 
to  the  fourth.  The 
relation  of  this  branch 
is  important.  In  the 
vast  majority  of  sub- 
jects it  will  be  found 
between  one  fourth 
and  three  fourths  of 
an  inch  to  the  inner 
side  of  the  inner  mar- 
gin of  the  scalenus 
anticus. 

The  left  vertehraJ 
(Fig.  292)  arises,  in 
4  per  cent  of  cases, 
from  the  aorta.     In 

most  subjects  it  wiU  be  found  within  three  fourths  of  an  inch  of  the  left 
scalenus  muscle. 

The  internal  rnarnniary  artery  arises  at  the  inner  border  of  the  sca- 
lenus anricus.  It  is  occasionally  from  the  thyroid  axis.  The  phrenic 
nerve  passes  usually  in  front,  occasionally  behind  it.  Behind  the  costal 
cartilages  it  runs  parallel  vdth  the  edge  of  the  sternum,  about  half  an 
inch  external  to  it. 

The  tfiyroid  axis  arises  also  just  within  the  scalenus.  The  inferior 
thyroid  branch  arises  from  the  axis,  in  almost  every  case  on  the  left  side. 
On  the  right,  in  twenty-six  cases  examined,  it  originated  from  the  in- 
nominate in  three,  and  directly  from  the  subclavian  in  three  instances. 
It  passes  upward  (inclining  at  first  a  little  inward)  until  it  arrives  at  a 
point  between  the  third  and  seventh  (incomplete)  rings  of  the  trachea, 
where  it  turns  abruptly  inward,  going  behind  the  common  carotid  and 
jugular,  in  front  of  the  vertebral,  and  is  distributed  chiefly  to  the  lower 
portion  of  the  thyroid  body. 

Tlhetransversalis  colli  passes  outward  in  front  of  the  scalenus  muscle 
and  the  phrenic  nerve,  underneath  the  omo-hyoid,  and  in  front  of  or 


Fig.  293.- 


Plan  of  the  ri»ht  subclavian  artery  and  its  branches.    From 
the  author's  dissections.     (Afiter  Quain.) 


256  A  TEXT-BOOK   ON  SURGERY. 

between  the  cords  of  tlie  brachial  plexus,  and  is  distributed  to  the  tra- 
pezius muscle,  sending  a  branch  in  the  direction  of  the  posterior  border 
of  the  scapula,  which  anastomoses  with  the  posterior  scapular  artery  ; 
and,  when  this  last  vessel  is  not  present,  this  descending  branch  is  con- 
tinued along  the  border  of  the  scapula  to  anastomose  with  the  subscapu- 
lar branch  of  the  axillary. 

The  suprascapular  artery^  intimately  associated  with  the  preceding, 
travels  suddenly  downward  and  outward  from  its  origin  near  the  inner 
edge  of  the  scalenus  anticus,  passes  between  the  subclavian  artery 
and  vein,  in  front  of  the  pTirenic  nerve,  crosses  in  front  of  the  third 
division  of  the  main  trunk,  and  goes  to  the  suprascapular  fossa  under 
the  protection  of  the  clavicle,  anastomosing  with  the  dorsalis  scapulce 
of  the  subscapular  is.  It  gives  oif  a  branch  (frequently  wounded  in 
operations  in  this  vicinity)  which  passes  behind  the  sterno-mastoideus 
and  along  the  upper  border  of  the  manubrium.  (It  is  not  usually  men- 
tioned.) 

The  right  superior  intercostal  artery  comes  from  the  second  division 
of  the  subclavian  in  almost  every  instance  ;  occasionally  from  the  first. 
The  left  is  usually  from  the  first  division. 

The  posterior  scapular,  one  of  the  most  important  branches  of  the 
subclavian,  in  a  surgical  view,  since  it  must  be  in  dangerous  proximity 
to  a  ligature  applied  in  the  third  surgical  division  (not  given  in  many 
standard  text-books,  except  as  an  occasional  branch  of  this  artery),  was 
present  in  thirty-six  of  fifty-two  dissections,  or  69  per  cent.  It  was 
present  in  nineteen  of  twenty-six  on  the  right  side,  and  in  seventeen  of 
twenty-six  on  the  left.  In  twenty-three  of  the  thirty-six  cases  in  which 
it  was  present  it  was  derived  from  the  thii'd  division  ;  in  the  remaining 
thirteen,  from  the  second  division,  close  to  its  outer  limit.  On  the  right 
side  74  per  cent  came  from  the  subclavian,  within  one  fourth  of  an  inch 
to  the  outer  and  inner  side  of  the  external  border  of  the  scalenus  muscle  ; 
26  per  cent  external  to  this. 

On  the  left  side  82  per  cent  were  within  one  fourth  of  an  inch  to  the 
outer  and  inner  side  of  the  line  dividing  the  middle  and  external  thirds 
of  the  main  trunk  ;  18  per  cent  were  to  the  outer  side  of  this.  The  tend- 
ency of  this  important  branch  is  to  originate  near  the  scalenus,  i.  e., 
within  one  fourth  of  an  inch  of  its  outer  edge.  When  this  vessel  is 
present  the  transversalis  colli  is  small,  and  when  absent  the  descending 
branch  of  the  ti'ansversalis  takes  its  distribution.  Passing  outward  be- 
hind the  most  superficial  cords  of  the  brachial  plexus,  it  turns  sharply 
downward,  along  the  posterior  border  of  the  scapula,  to  anastomose  with 
the  subscapular  branch  of  the  axillary. 

Operation — The  Right  Subclavian  in.  its  First  Surgical  Division. — 
The  incisions  are  the  same  as  for  the  arteria-innominata  (Fig.  279). 
When  the  sterno-hyoid  and  sterno-thyroid  muscles  have  been  divided 
on  the  director,  the  internal  Jugular  vein  will  be  seen  directly  in  front 
of  the  artery.  It  may  be  drawn  to  the  inner  side  (or  outer,  if  more 
convenient),  carefully  using  for  this  purpose  a  dull  retractor.  Care 
must  be   exercised   not   to   injure   the   pleura  which    rises  against  the 


LIGATION  OF  ARTERIES.  257 

artery  in  deep  inspiration.  A  dnll-pointed  anenrism-needle  may  now 
be  passed  around  the  vessel,  taking  care  not  to  wound  the  subclavian 
or  innominate  vein,  or  the  recurrent  laryngeal  nerve.  The  vertebral, 
internal  inammary,  and  branches  of  the  thyroid  axis,  should  also  be 
secured. 

The  conditions  which  will  justify  this  operation  will  rarely  occur,  yet, 
when  the  operation  is  demanded,  every  source  of  danger  from  hasmor- 
rhage  should  be  avoided.  The  necessity  of  securing  the  carotid  at  the 
same  operation  must  be  determined  by  the  operator.  I  am  of  the  opinion 
that  it  is  safer  to  occlude  this  vessel  also. 

The  subclavian  artery  has  been  tied  in  its  first  surgical  division  eight- 
een times,  and  all  fatal.  In  five  of  these  cases  the  common  carotid  was 
also  tied.  In  only  one  case  was  the  left  subclavian  tied.  Of  the  thirteen 
single  operations,  two  (Ayres  and  Bullen)  were  for  the  arrest  of  haemor- 
rhage from  shot  wounds  in  military  practice,  with  one  death  in  half  an 
hour  and  one  on  the  eighth  day,  from  hsemorrhage.  The  other  eleven 
cases  are  given  on  page  225.  In  only  five  of  these  thirteen  cases  is  the 
source  of  hsemorrhage  stated,  and  in  each  of  these  the  bleeding  was  from 
the  distal  side  of  the  ligature,  the  proximal  side  being  closed.*  A 
knowledge  of  this  fact  leads  me  to  insist  upon  the  ligation  of  the  verte- 
bral and  other  branches  of  the  first  division. 

In  five  instances  the  right  carotid  was  also  tied  simultaneously  by 
Liston,  Parker,  Hobart,  Cruveilhier,  and  Kiihl.  In  three  of  these,  fatal 
haemorrhage  ensued  from  the  distal  side  of  the  ligature. 

The  left  subclavian  artery  was  tied  in  its  first  division  once  by 
Rodgers,  and  fatal  haemorrhage  occurred  from  the  distal  end  of  the 
artery. 

Ligation  of  the  Left  Subclavian  Artery  in  its  First  Surgical  Divis- 
ion— Operation. — From  a  point  on  the  clavicle  one  fourth  the  distance 
from  the  center  of  the  interclavicular  notch  to  the  acromion  process  com- 
mence an  incision,  and  carry  it  to  the  inner  border  of  the  sternal  tendon 
of  the  mastoid  muscle.  From  the  inner  extremity  of  this  line  carry  a 
second  incision  for  three  inches  along  the  anterior  border  of  the  sterno- 
mastoideus.  In  dissecting  this  flap  lift  with  it  the  mastoid  muscle  divided 
upon  the  director,  then  divide  the  sterno-hyoid  and  thyroid  mxiscles,  and 
feel  for  the  pulsation  of  the  artery,  which  ascends  deeply  behind  and  a 
little  outside  the  sterno-clavicular  articulation.  The  internal  jugular 
vein  will  be  drawn  outward,  and,  passing  the  finger  along  the  inner  bor- 
der of  the  scalenus  muscle,  the  artery  will  be  felt  to  pulsate  (Fig.  281). 
The  thoracic  duct  usually  is  to  the  right  of  and  a  little  behind  the  artery 
opposite  the  upper  border  of  the  sternum.  On  a  level  with  the  insertion 
of  the  scalenus  it  arches  to  the  left,  crosses  in  front  of  the  subclavian, 
in  front  of  the  scalenus,  behind  the  internal  jugular,  and  curves  down- 
ward to  empty  into  the  subclavian  at  its  junction  ■with  the  jugular  to 
form  the  left  innominate  vein.  On  account  of  the  intimate  relations  of 
the  thoracic  duct  to  the  left  subclavian  artery  as  this  vessel  goes  behind 

*  The  author's  "Essays,"  William  Wood  &  Co.,  1878. 


258  ■  A   TEXT-BOOK    ON   SURGERY. 

the  scalenus^  the  ligature  should  not  be  attempted  close  to  this  muscle, 
nor  should  the  dissection  be  carried  fully  to  the  scalenus.  The  artery 
should  be  tied  as  low  down  as  possible,  the  duct  being  less  likely  to  be 
injured  here,  since  in  passing  behind  the  aorta  it  is  deeper  than  the 
artery.  It  will  be  found  behind  and  to  the  right,  the  pneumogastric  in 
front  and  to  the  right,  the  left  vena  innominata  crossing  in  fi'ont,  while 
the  pleura  is  directly  behind. 

The  vertebral  and  other  branches  of  the  left  subclavian  are  in  such 
proximity  to  the  thoracic  duct  that  it  will  be  dangerous  to  attempt  to  tie 
them  at  this  point. 

Ligation  of  the  Subclavian  Arteries  in  their  Second  and  Third  Sur- 
gical Divisions — Operation. — The  procedure  is  essentially  the  same  on 
the  two  sides.  Place  the  shoulders  ui)on  a  cushion,  pull  downward  on 
the  arm  of  the  side  to  be  operated  upon,  and  turn  the  patient's  face  to  the 
opposite  side.  Find  the  location  of  the  scalenus  anticus,  as  in  the  pre- 
ceding operation.  Slide  the  skin  well  down  upon  the  clavicle,  and  along 
this  bone  make  an  incision  three  or  four  inches  in  length,  commencing 
one  inch  to  the  inner  side  of  the  scalenus  muscle  and  terminating  near 
the  anterior  edge  of  the  trapezius.  Allowing  the  skin  to  resume  its  nor- 
mal relations,  the  incision  will  be  carried  above  the  clavicle.  Upon  a 
director  divide  the  outermost  of  the  clavicular  fibers  of  the  mastoid 
muscle.  The  internal  jugular  vein.,  seen  in  the  anterior  portion  of  the 
wound,  will  be  carefully  drawn  to  the  inner  sid-e,  the  ox^erator  keeping 
well  above  the  Junction  of  this  with  the  subclavian,  and  thus  avoiding 
the  lymphatic  duct. 

A  prominent  plexus  or  group  of  veins,  viz.,  the  external  jugular, 
transversalis  colli,  and  suprascapular,  will  be  seen  traversing  the 
wound,  coming  from  their  respective  origins,  toward  the  subclavian, 
near  the  jugular.  These  should  be  secured  with  a  double  ligature,  and 
divided,  or  held  aside.  Dissecting  carefully,  the  suprascapular  and 
transversalis  colli  arteries  will  be  observed  running,  in  general,  in  the 
direction  of  the  first  incision.  The  posterior  belly  of  the  omo-Tiyoid  may 
be  found  in  the  uj)per  margin  of  the  wound,  crossing  the  scalenus  at 
about  a  right  angle.  The  transversalis  colli  and  the  suprascapular  may 
be  secured  or  held  to  one  side,  the  finger  passed  along  the  scalenus  until 
the  tubercle  on  the  first  rib  is  felt,  immediately  behind  which  the  artery 
will  be  found.  If  it  shall  have  been  determined  to  tie  the  artery  in  its 
second  portion,  the  scalenus  anticus  muscle  will  be  cut  upon  a  direc- 
tor, the  operator  being  careful  to  avoid  the  phrenic  nerve,  which  crosses 
the  muscle  in  front,  coming  from  above  downward  and  inward.  (It  is 
between  the  layers  of  the  sheath  of  this  muscle.)  The  ligature  is  next 
passed  around  the  artery  from  before  backward,  care  being  taken  not  to 
wound  the  pleura. 

If  the  third  division  of  the  artery  is  to  be  secured,  the  j)art  of  the 
above  operation  relating  to  the  division  of  the  scalenus  will  be  omit- 
ted. The  nearest  cord  of  the  brachial  plexus  must  be  carefully  ex- 
cluded, posteriorly  to  the  artery  ;  the  subclavian  vein  in  front  and  be- 
low (Fig.  289). 


LIGATIOX   OF   ARTERIES.  259 

The  subclavian  arteries  have  been  tied  behind  the  scalenus  anticus 
thirteen  times,  with  fonr  recoveries.  All  of  the  fatal  cases  were  on  the 
right  side. 

In  one  of  the  "Prize  Essays"  of  the  American  Medical  Association  I 
pnblished  the  histories  of  two  hnndred  and  fifty-one  ligations  of  the  sub- 
clavian artery  in  its  thii'd  surgical  division,  of  which  one  hundi-ed  and 
thirty- four  ended  fatally.  As  far  as  these  histories  relate  to  aneurism 
they  have  been  given.  A  study  of  the  remaining  cases  led  me  to  con- 
clude that  in  all  lesions  causing  dangerous  hsemorrhage  in  the  upper 
brachial  or  axillary  regions  an  effort  should  be  made  to  control  the  bleed- 
ing at  the  seat  of  injury.  Failing  in  this,  deligation  of  the  subclavian, 
in  its  third  division,  is  demanded. 

Ligation  of  the  Vertebral  Artery — Operation. — Locate  by  pressure 
the  carotid  tubercle  (the  transverse  process  of  the  sixth  cervical  vertebra). 
The  point  at  which  the  artery  is  to  be  secured  is  one  inch  directly  below 
this  bony  prominence,  which  must  be  the  center  of  a  peri^endicular  in- 
cision, four  inches  in  length.  Commence  the  incision  at  the  outer  bor- 
der of  the  sterno-mastoid  muscle,  where  the  external  jugular  vein 
crosses.  The  internal  jugular  is  seen  and  drawn  inward.  The  transverse 
cervical  artery,  and  one  or  two  smaller  veins,  are  met  with  next,  and 
drawn  to  the  outer  side  of  the  wound.  The  scalenus  anticus  muscle  is 
now  brought  into  view,  and  to  the  inner  side  of  this  a  depression  be- 
tween this  muscle  and  the  longus  colli.  In  this  sulcus  the  artery  lies, 
the  vein  being  in  fi'ont  of  it.  In  my  case  I  had  to  tie  the  vein  with 
a  double  ligature,  divide,  and  turn  the  ends  aside  in  order  to  secure  the 
artery. 

Ligation  of  the  Internal  Mammary — Operation. — This  vessel  may 
be  secured,  as  has  been  described,  close  to  the  parent  trunk,  or  ir  may 
be  tied  in  one  of  the  intercostal  spaces.  In  the  third  or  fourth  space 
make  an  incision,  about  two  inches  in  length,  obliquely  from  without 
inward  and  downward,  the  center  of  which  should  be  about  half  an 
inch  external  to  the  edge  of  the  sternum.  Divide  the  fibers  of  the 
pectoralis  major  and  the  intercostal  muscle,  and  clear  away  the  tissues 
with  a  blunt-pointed  iastrument.  The  artery,  with  its  venee  comites, 
will  be  seen  in  front  of  the  fibers  of  the  triangularis  sterni,  which  sepa- 
rates it  from  the  pleura  on  the  right  and  the  mediastinum  on  the  left 
side.  In  separating  the  veins  fi'om  the  artery,  care  should  be  taken 
not  to  break  through  the  thin  structure  between  the  vessel  and  the 
cavity. 

The  other  branches  of  the  subclavian  artery  do  not  require  especial 
consideration.  The  inferior  thyroid  is  often  tied  in  the  removal  of 
goitre.  I  have,  in  six  operations,  found  and  deligated  it  prior  to  ab- 
lation of  a  bronchocele.  It  will  usually  be  seen  on  the  tracheal  side 
of  the  common  carotid.,  just  below  the  anterior  belly  of  the  omo- 
hyoid. 

Ligation  of  the  Axillary  Artery — Anatomy. — This  artery  may  be 
tied  at  any  part  of  its  course.  On  account,  however,  of  the  difficulty  of 
approach  of  that  portion  beneath  the  pectoralis  minor,  it  is  usually 


260  A  TEXT-BOOK   ON  SURGERY. 

secured  in  the  axilla,  below  this  point,  or  between  the  upper  margin  of 
this  muscle  and  the  lower  border  of  the  first  rib. 

Operation. — With  the  head  thrown  back  and  the  shoulders  elevated, 
allow  the  arm  to  remain  by  the  side  of  the  body.  About  two  inches  from 
the  sternal  end  of  the  clavicle,  and  half  an  inch  below  its  inferior  border, 
carry  an  incision  outward,  parallel  with  this  bone,  a  distance  of  from 
three  to  four  inches.  This  incision  may  divide  a  superficial  vein  which 
passes  from  the  cephalic  over  the  clavicle.  The  clavicular  fibers  of  the 
pectoraiis  major  and  the  costo-coracoid  membrane  are  divided  upon 
the  director.  The  axillary  vein  will  then  be  seen  in  the  anterior  por- 
tion of  the  wound,  lying  in  front  of  the  artery,  which  may  be  felt  to 
pulsate,  or  seen  just  external  to  it.  More  external  still  may  be  seen 
the  anterior  cord  of  the  brachial  plexus,  while  in  the  lower  portion  of 
the  wound  the  cephalic  vein  crosses  over  to  empty  into  the  axillary, 
below  the  clavicle.  Beneath  the  clavicle  the  subclavius  muscle  may 
be  seen.  The  needle  should  be  passed  from  before  backward.  If 
necessary,  a  second  incision  may  be  made,  beginning  in  the  center  of  the 
first  and  carried  in  the  direction  of  the  axilla,  as  recommended  by  Cham- 
berlain. 

This  operation  is  somewhat  more  difiicult  than  ligation  of  the  sub- 
clavian in  its  third  division,  but  it  is  preferable,  on  account  of  being 
farther  removed  froiia  the  heart.  Delpech  advised  an  incision  beginning 
at  the  junction  of  the  middle  and  outer  third  of  the  clavicle,  and  sepa- 
rating the  deltoid  and  pectoraiis  muscles. 

Operation  below  the  Pectoraiis  Minor. — Shave  and  cleanse  the  axilla, 
and  extend  the  arm  at  a  right  angle   to  the  body.     Divide  the  dis- 

fcllio,,,  .  ,.|i^!iill'f '  "'*iCTI"li!!iliiii||l,' 

"If iljll::. 


Fig.  294. — Ligation  of  the  axillary  in  its  lower  third. 


tance  between  the  two  folds  of  the  axilla  into  thirds,  and  the  junction 
of  the  anterior  and  middle  thirds  will  indicate  the  position  of  the  artery. 
On  this  line  make  an  incision  in  the  axis  of  the  arm,  well  up  into  the  ax- 
illa.    Cutting  through  the  skin  and  fascisE,  the  contents  of  this  space  will 


LIGATION^   OF   ARTERIES. 


261 


be  seen.  The  vein  lies  internal  to 
the  artery,  often  overlapping  it,  and 
should  be  drawn  carefully  backward. 
The  median  nerve  overlies  the  artery, 
or  is  on  its  anterior  aspect,  and 
should  be  drawn  forward  when  the 
needle  is  passed  from  behind  forward 
(Fig.  294). 

Ligation  of  the  Brachial  Artery 
— Anatomy. — This  aVtery  lies  in  the 
furrow  along  the  inner  border  of  the 
coraco-brachialis  and  biceps  muscles, 
tending  more  and  more  to  the  front 
as  it  nears  the  elbow-joint.  In  the 
lower  half  or  three  fourths  of  its 
course  it  has  its  vense  comites  on 
either  side,  with  occasional  commu- 
nications across  the  track  of  the  ar- 
tery. The  median  nerve  crosses  it 
by  the  front,  from  the  outer  side, 
on  its  way  to  the  forearm,  while 
the  basilic  vein  is  well  to  the  in- 
ner side.  As  this  vein  passes  up 
toward  the  axilla  it  pierces  the  deep 
fascia,  and  lies  on  the  inner  side  and 
close  to  the  artery,  joining  with  the 
venge  comites  to  form  a  single  large 
trunk. 

Operation. — A  line  drawn  from 
the  junction  of  the  middle  and  ante- 
rior thirds  of  the  axillary  space  (as 
above  given)  to  the  middle  of  the 
elbow-joint,  in  front,  will  pass  over  the 
brachial-  artery  in  its  entire  length. 
The  place  of  election  is  the  middle  of 
the  arm.  At  this  point  make  an  in- 
cision, three  inches  in  length,  over 
the  artery  and  in  its  axis.  Divid- 
ing the  skin  and  deep  fascia,  the 
white  cord  of  the  median  nerve  will 
be  first  seen,  on  the  outer  side  of  the 
brachial,  overlapping  the  companion 
vein  on  this  side.  Just  internal  to 
this  is  the  artery,  with  the  other  ac- 
companying vein  and  the  basilic  in 
close  relation  (Fig.  295).  The  liga- 
ture should  be  passed  from  the  in- 
ner toward  the  outer  side.     The  op- 


FiG.  295.— Ligation  of  tiie  biacliial  near  tbo 
middle  and  the  lower  tlurd. 


262  A  TEXT-BOOK  ON  SURGERY. 

eration  above  this  point  is  essentially  the  same.  In  the  lower  third 
of  the  arm  proceed  as  follows :  On  a  level  with  the  condyles  of  the 
humerus,  and  between  the  median  basilic  vein  and  the  tendon  of  the 
biceps,  commence  an  incision,  which  is  carried  upward  three  inches 
in  the  brachial  line.  Cutting  through  the  deep  fascia,  the  artery  is 
readily  found  to  the  radial  side  of  the  median  nerve,  and  surround- 
ed by  its  veins  (Fig.  297).  The  needle  is  passed  from  the  inner  side. 
Occasionally  the  brachial  artery  is  double,  while  more  frequently  it 
bifurcates  into  the  radial  and  ulnar,  at  a  varying  distance  above  the 
elbow. 

Ligation  of  the  Ulnar  and  Radial  Arteries.^— The  radial  artery 
may  be  tied  immediately  above  the  wrist,  or  in  the  upper  third  of 
the  arm. 

Operation  at  the  Wrist. — A  vertical  incision,  one  inch  and  a  half 
long,  is  made  in  the  center  of  the  dej)ression,  between  the  outer  bor- 
der of  the  radius  and  the  radial  border  of  the  extensor  carpi  radialis 
muscle.  Immediately  beneath  the  deep  fascia  the  artery  will  be  ob- 
served, with  its  vence  comites,  from  which  it  is  separated  and  tied 
(Fig.  296). 

To  iind  the  artery  in  the  upper  third,  draw  a  line  from  the  middle 
of  the  elbow-joint,  in  front,  to  the  styloid  process  of  the  radius.  Along 
this  line  make  an  incision,  about  three  inches  in  length,  avoiding  the 
superficial  veins,  if  possible.  Cutting  directly  down,  the  artery  will  be 
found  between  the  supinator  longus  externally  and  the  pronator  radii 
teres  on  the  ulnar  side.  The  radial  nerve  is  well  to  the  radial  side,  and 
the  vense  comites  on  either  side  (Fig.  297). 

The  ulnar  artery  may  be  tied  at  the  bend  of  the  elbow,  and  near  the 
wrist.  As  it  passes  beneath  the  pronator  radii  teres  and  flexor  muscles, 
it  is  so  deeply  situated  that  an  attempt  to  deligate  it  here  is  not  justifi- 
able. Above  this  point  it  may  be  secured  by  a  downward  extension  of 
the  incision  given  for  ligature  of  the  brachial  at  the  bend  of  the  elbow 
(Fig.  297). 

Near  the  wrist-joint  an  incision  should  be  made  about  a  quarter  of 
an  inch  to  the  radial  side  of  the  tendon  of  the  flexor  carpi  ulnaris  muscle. 
This  incision  should  commence  one  inch  above  the  level  of  the  pisiform 
bone,  and  extend  upward  one  inch.  The  ulnar  nerve  will  be  seen  partly 
concealed  by  the  tendon,  while  the  artery  and  its  accompanying  veins 
are  immediately  on  its  radial  side  (Fig.  296). 

Ligation  of  the  Intercostal  Arteries — Anatomy. — The  artery  lies  be- 
hind and  near  the  lower  border  of  the  rib,  the  vein  above,  and  the  nerve 
below  it.  From  near  the  angle  of  the  rib  to  the  vertebral  column  it  is 
separated  from  the  thoracic  cavity  by  the  pleura  alone,  but  in  front  of 
this  it  runs  between  the  two  layers  of  intercostal  muscles. 

Operation. — An  incision  should  be  made  just  along  the  lower  bor- 
der of  the  rib.  After  passing  through  the  outer  plane  of  intercostal 
muscles  the  artery  may  be  seen  and  secured.  Or,  failing  in  this, 
take  a  long,  curved  aneurism-needle,  and  through  a  puncture  near 
the  lower  border  of  the  rib  pass  it  behind  the  artery  and  around  the 


LIGATIOX    OF   ARTERIES. 


263 


Fig.  i96. — ^Li^atioa  of  the  ulnar  and  radial 
arteries  of  the  "wrisU 


Fig.  29T. — T.JTatinTi  of  the  radial  in  the  middle  of  the 
forearm  and  of  the  Brachial  at  tiie  bend  of  the  elbow- 


264  A  TEXT-BOOK  ON   SURGERY. 

rib,  taking  care  not  to  puncture  the  pleura.  When  the  point  of  the 
needle  is  felt  at  the  upper  margin  of  the  bone,  another  puncture  is 
made  to  allow  its  escape.  The  needle  is  now  armed  with  a  strong  cat- 
gut and  withdrawn.  A  pellet  of  sublimate  gauze  is  laid  over  the  skin, 
between  the  points  of  exit  and  entrance,  around  which  the  ligature  is 
tied.  In  exceptional  cases  it  may  be  necessary  to  I'emove  a  portion  of 
the  rib. 

Ligation  of  the  Abdominal  Aorta — Anatomy. — The  aorta  usually 
bifurcates  upon  the  body  of  the  fourth  lumbar  vertebra,  a  little  to 
the  left  of  the  median  line.  This  point  is  on  a  level  with  the  high- 
est point  of  the  iliac  crests,  and  is  a  little  to  the  left  of  and  below 
the  umbilicus.  The  point  of  election  is  one  inch  above  the  bifurca- 
tion. 

Operation,  Median. — In  the  linea  alba  make  an  incision,  six  inches 
long,  the  center  of  which  corresponds  to  the  umbilicus.  When  within 
an  inch  of  the  navel,  curve  to  the  left  three  fourths  of  an  inch,  and  one 
inch  farther  on  regain  the  middle  line.  Divide  all  the  tissues  down  to 
the  parietal  peritonaeum,  and  then  arrest  all  bleeding  before  opening  this. 
After  opening  into  the  cavity,  the  transverse  colon  should  be  displaced 
upward,  and  the  small  intestines  brought  out  through  the  wound  and 
secured  in  a  soft  rubber  cloth,  kept  warm  with  sublimate  towels.  With 
the  finger-nail  or  a  blunt  director  scratch  through  the  peritonaeum  and 
expose  the  aorta,  around  which  a  large  animal  (or  silk)  ligature  should 
be  passed  from  the  right  side. 

Lateral  Incision. — From  the  free  end  of  the  left  eleventh  rib  com- 
mence an  incision,  which  carry  downward  to  within  three  fourths  of  an 
inch  of  the  anterior  superior  iliac  spine,  thence  parallel  with  Poupart's 
ligament  to  its  middle.  Divide  the  three  abdominal  muscles  down  to 
the  parietal  peritonaeum.  When  this  is  reached,  use  the  fingers,  the 
nails  of  which  have  been  closely  pared,  and  lift  the  peritonaeum  from  the 
posterior  abdominal  wall.  Passing  over  the  posterior  iliac  crests  and  into 
the  iliac  fossa,  the  ridge  formed  by  the  psoae  muscles  is  reached  and 
must  be  crossed.  The  lumbar  nerves  and  ureter  should  be  avoided,  and, 
by  a  free  dilatation  of  the  wound  and  concentration  of  light,  the  aorta 
may  be  seen  and  tied,  about  three  inches  above  the  lumbo-sacral  junc- 
tion. Of  these  two  procedures  the  former  is  anatomically  and  surgically 
preferable.  * 

Ligation  of  tlie  Common  Iliac  Artery — Anatomy. — The  common 
iliac  arteries  extend  from  the  left  side  of  the  body  of  the  fourth  lum- 
bar to  the  sacro-lumbar  junction.  It  is  crossed  by  the  ureter  in  front, 
near  its  bifurcation,  and  by  some  filaments  of  the  sympathetic  nerve 
higher  up.  The  left  common  iliac  vein  lies  wholly  internal,  and  is 
on  a  plane  somewhat  deeper  than  the  artery.  The  inferior  mesen- 
teric vein  crosses  the  left  artery,  but  is  within  the  peritoneal  folds. 
The  right  iliac  artery  crosses  in  front  of  both  the  iliac  veins,  passing 
at  a  right  angle  to  the  left  vein  and  obliquely  over  the  right,  until 

*  The  abdominal  aorta  has  been  tied  ten  times,  all  fatal. 


LIGATION   OF   ARTERIES. 


265 


near  its  termination  the  artery  is  in  front  of  and  external  to  the  vein 
(Fig.  298). 

Operation — Anterior  Incision. — Make  an  incision  in  the  linea  alba  ex 
tending  from  about  one  inch  above  to  about  five  inches  below  the  umbili 
cus.  Avoid  the  umbilicus  as  directed  in  the  ligation  of  the  aorta.  Arrest 
all  bleeding  before  the  parietal  peritonaeum  is  opened.  When  this  is  done, 
draw  the  small  intestines  out  through  the  wound  and  protect  them  in  a 


-Dissection  showing  the  relation  of  the  right  oomirion  e.^temal  and  internal  iliac  arteries  and  veins 
The  ureter  is  seen  crossing  the  iliac  near  the  bitiiroation. 


soft,  clean  rubber  cloth,  kept  warm  by  sublimate  towels.  The  posterior 
wall  of  the  peritonaeum  is  scratched  through  by  means  of  two  dissecting- 
forceps  and  the  aneurism -needle  passed  from  within  out. 

18 


266 


A  TEXT-BOOK   ON  SURGERY. 


Lateral  Incision. — Same  as  for  the  aorta.*  The  anterior  incision  is 
preferable. 

Ligation  of  the  Internal  and  External  Iliac  Arteries — Anatomy. — 
The  internal  iliac  artery,  less  than  two  inches  in  length,  has  the  nreter 
in  front,  its  accompanying  vein  and  the  lumbo-sacral  nerve  behind. 

Operation. — Through  the  PeritoncBum.  —  Proceed  as  in  the  same 
operation  for  the  primitive  iliac.  If  necessary,  a  transverse  incision 
may  be  added  to  that  in  the  linea  alba. 

Behind  the  PeritoncBum. — One  inch  and  a  half  internal  to  the  anterior 
superior  spine  of  the  ilinm  begin  an  incision,  vsrhich  travels  downward 
and  inward  across  the  track  of  the  external  iliac.  Be  careful  not  to  carry 
the  deep  incision  far  enough  internally  to  divide  the  epigastric  artery. 
Cut  down  to  the  parietal  peritoneeum,  and  separate  this  from  its  attach- 


FiG.  299. — Ligation  of  the  gluteal,  internal  pudic,  and  sciatic  arteries. 


*  This  artery  has  been  tied  about  seventy  times.     For  aneurism  about  33  per  cent  recovered, 
while  for  hsamorrhage  almost  every  case  ended  fatally. 


LIGATION   OF   ARTERIES. 


267 


ment  to  tlie  abdominal  -wall  and  iliac  fossa,  along  the  iliac  artery.  When 
the  bifurcation  is  reached,  draw  firmly  with  a  retractor  upon  the  upper 
lip  of  the  wound  and  pass  the  needle  from  the  inner  side.*  This  opera- 
tion may  be  demanded  in  sciatic  or  gluteal  aneurism,  or  h?emorrhage 
from  these  vessels.     The  former  method  is  preferable. 

The  Gluteal  Artery. — Make  a  five-iuch  incision,  on  a  line  extending 
from  the  spine  of  the  last  lumbar  vertebra  to  the  trochanter  major.  The 
center  of  this  line  wiU  indicate  the  point  at  which  the  artery  emerges. 
Separate  with  a  dull  instrument  the  fibers  of  the  gluteus  niaximus,  dis- 
place anteriorly  the  gluteus  medius,  and  find  the  groove  between  the 
minimus  and  the  pyriformis.  FoUow  this  groove  upward  to  the  bony 
edge  of  the  notch,  and  the  artery  and  veins  will  be  found  (Fig.  299,  upper 
incision). 


Fig.  300. — ^Ligatdon  of  the  interoal  pudlc  ia  the  perinseum. 

The  Sciatic. — Make  an  incision,  five  inches  long,  on  a  line  from  the 
middle  of  the  sacral  spines  to  the  trochanter  major.  Separate  the  fibers 
of  the  gluteus  maximus  and  find  the  lower  border  of  the  pyriformis.     The 

*  The  internal  iliac  has  been  tied  about  thirt}-  times,  n  itii  a  death-rate  of  66  per  cent. 


268 


A  TEXT-BOOK   ON  SURGERY. 


great  cord  of  the  sciatic  nerve  will  now  be  seen  emei'ging  from  beneath 
the  muscle,  and  immediately  in  front  of  this  the  small  sciatic  nerve  and 
the  sciatic  artery.  The  internal  pudic  artery  is  just  anterior  to  this, 
upon  the  spine  of  the  ischium  (Fig.  299,  middle  incision).  The  sciatic 
artery  may  also  be  secured  opposite  the  tuber  iscMi,  along  the  outer  bor- 
der of  which  it  runs  (Fig.  299,  lower  incision). 

The  Infernal  Pudic  in  the  PerincBum. — With  the  patient  supine 

and  the  thigh  abducted, 
^^fflWfflillffiiiiiffl^^^^^^Ml^fflSBi^^^  make  an  incision  in  a  line 

with  the  symphysis  pubis 
and  tuber  ischii.  The 
artery  will  be  found  as 
it  runs  along  the  inner 
margin  of  the  ramus  of 
the  pubis  (Fig.  300). 

Ligation  of  the  Ex- 
ternal Iliac  in  its  Lower 
Portion. — The  external 
iliac  has  in  relation  to  it 
the  accompanying  vein 
internally.  The  spermat- 
ic vessels  cross  it,  and  in 
the  male  the  vas  deferens 
is  internal  to  it  at  the  in- 
guinal ring. 

Operation. — One  inch 
to  the  inner  side  of  the 
anterior  superior  spine 
of  the  ilium  commence 
an  incision,  which  is  car- 
ried in  the  direction  of 
the  middle  of  Poupart's 
ligament,  and  terminates 
one  inch  above  this  point, 
without  entering  the  in- 
ternal ring.  Divide  the 
three  muscles  down  to 
the  transversalis  fascia, 
arrest  all  bleeding,  divide 
the  fascia  carefully,  re- 
tract the  upper  lip  of  the 
wound,  and  lift  the  peri- 
tongeum  from  the  iliac 
fossa  and  artery  (Fig.  301).  Displace  any  overlying  lymphatics  and  in- 
troduce the  needle  from  the  inner  side.* 


-Ligation  of  the  external  iliac  in  its  lower  portion, 
of  the  femoral  in  Hunter's  canal. 


*  Ligation  of  the  external  iliac  has  proved  fatal  in  almost  every  instance  in  which  it  was  tied 
for  haemorrhage.     For  aneurism  about  67  per  cent  recover. 


LIGATION    OF   ARTERIES. 


269 


The  deep  circumflex  and  the  epigastric  branches,  which  arise  about 
half  an  inch  above  the  ligament,  may  also  be  tied  by  this  incision.  In 
its  npper  portion  this  vessel  may  be  secured  by  the  same  operation  as  for 
the  common  iliac. 

Ligation  of  the  Femoral  Artery — Anatomy. — At  Poupart's  ligament 
the  vein  is  on  the  same  plane  as  the  artery,  and  immediately  internal  to 
it.  One  quarter  of  an  inch  to  the  outer  side,  and  deeper  than  the  artery, 
lies  the  anterior  crural  nerve.  One  inch  and  a  half  fi'om  the  ligament  the 
profunda  femoris  arises  from  the  outer  aspect  of  the  common  trunk, 
and  from  one  to  two  inches  lower  passes  behind  the  supeiiicial  femoral. 
Four  inches  fi'om  Poiipart's  ligament  the  relations  have  changed  to  such 


Fig.  802. — Ligation  ot  the  superficial  femoral  in  Scarpa's  space. 

an  extent  that  the  femoral  vein  is  deeper  and  slightly  behind  the  artery. 
The  long  saphenous  nerve  lies  upon  the  sheath  of  the  artery,  in  its  middle 
third,  and  occasionally  sends  a  branch  through  Huntefs  canal.  The 
sartorius  muscle  covers  the  femoral  artery  in  all  of  its  course  except  the 
first  four  inches,  where  it  is  superficial. 

Operation.— X  line  from  a  point  half  way  between  the  symphysis 
pubis  and  the  anterior  superior  spine  of  the  ilium  to  the  internal  condyle 


270 


A  TEXT-BOOK   ON  SURGERY. 


of  tlie  femur  will  run  over  and  parallel  with  the  femoral.     It  may  be 
secured  in  any  part  of  its  course. 

In  Scarpa's  Space. — The  point  of  election  for  tying  the  superficial 
femoral  is  from  four  to  five  inches  below  Poupart's  ligament.  With  this 
as  the  center,  make  an  incision  three  inches  long  on  the  line  already  indi- 
cated. Beneath  the  skin  and  fascia  some  superficial  and  unimportant 
vessels  may  be  divided  ;  the  fibers  of  the  sartorius  will  be  seen  in  the 
lower  portion  of  the  wound,  and  should  be  drawn  downward  with  a  re- 
tractor. The  saphenous  nerve  will  next  be  seen  on  the  outer  side  of  the 
common  sheath  of  the  vessels.  The  sheath  should  next  be  incised,  and 
the  artery  carefully  isolated  by  inserting  a  dull  director  beneath  and 
around  it  from  the  inner  side.     The  ligature  is  passed  the  same  way. 


Fie.  303. — Ligation  of  the  deep  and  superficial  femoral  near  the  bifurcation  of  the  common  femoral,  and 
in  the  apex  of  Scarpa's  triangle. 

In  this  same  plane  an  incision  may  be  made  to  expose  the  artery 
lower  down,  where  it  is  completely  hidden  by  the  sartorius.  This  mus- 
cle may  be  drawn  to  the  side  most  convenient  to  the  operator  (Figs. 
302,  303). 

In  Hunter's  Canal. — Find  the  junction  of  the  middle  and  lower  thirds 
of  the  thigh.  In  the  femoral  line,  with  this  point  as  the  center,  make  an 
incision,  about  four  inches  in  length,  directly  down  to  the  sheath  of  the 


LIGATION    OF   ARTERIES. 


271 


sartorms,  which  is  incised  and  the  muscle  displaced  outward.  Imme- 
diately upon  opening  the  posterior  layer  of  the  sheath  of  the  muscle,  the 
oblique  aponeurotic  fibers  which  pass  from  the  adductor  magnus  to  the 
vastus  internus — forming  the  anterior  waU  of  Hunter's  canal — are  seen. 
These  may  be  divided  on  a  director,  or  the  sheath  opened  half  an  inch 
above  this  point.  The  saphenous  nerve  is  on  the  sheath,  and  the  vein  is 
behind  and  to  the  outer  side  (Fig.  304). 

The  Common  Femoral  above  the  Profunda. — Make  an  incision  in  the 
femoral  line,  from  three  fourths  of  an  inch  above  Poupart's  ligament 
downward  for  three  inches  and  a  half.  Do  not  divide  the  ligament,  but 
approach  the  artery  one  half  inch  below.  The  superficial  epigastric 
vein  and  artery  may  be  wounded. 
Divide  the  fascia  lata,  and  pass  the 
ligature  from  within  out.  (Dissec- 
tion shown  in  Figs.  302,  303.) 

The  Profunda  Femoris.  — 
Make  an  incision  in  the  femoral 
line,  three  inches  and  a  half  long, 
the  center  opposite  a  point  one 
inch  and  a  half  to  two  inches  below 
Poupart's  ligament.  As  above, 
approach  the  common  trunk  and 
search  along  its  outer  border  for 
the  origin  of  the  profunda*  (Fig. 
303).  Pass  the  ligature  from  with- 
in out,  one  inch  from  its  origin. 
Avoid  the  branches  of  the  ante- 
rior crural  nerve. 

In  wounds  of  the  posterior  fem- 
oral region  it  may  be  necessary 
to  tie  this  vessel  as  well  as  for 
aneurism.  Ligation  of  the  com- 
mon femoral  is  rarely  called  for, 
and  should  only  be  done  in  ex- 
treme cases.  In  modern  surgical 
practice,  deligation  of  the  super- 
ficial femoral  is  comparatively  free 
from  danger. 

Ligation  of  the  Popliteal — 
Operation. — Place  the  patient  on 
his  belly,  with  the  popliteal  space 

looking  upward.  Make  an  incision,  four  inches  long,  beginning  two 
inches  and  a  half  above  the  level  of  the  joint,  at  the  outer  edge  of  the 
semi-membranosus  tendon,  and  extending  down  through  the  middle  of 
the  space.     Dividing  the  dense,  deep  fascia,  the  areolar  tissue  which  sur- 


FiG.  304.— Ligation  of  the  popliteal  artery.    Eelations 
of  contents  in  the  left  lower  extremity. 


*  In  a  large  majority  of  subjects  T  have  found  this  branch  given  off  one  inch  and  a  half  be- 
low the  ligament. 


272 


A   TEXT-BOOK    ON   SURGERY. 


rounds  the  vessels  and  nerves  of  the  space  will  be  seen,  and  at  the  same 
time,  and  superficially,  the  popliteal  nerve.  Draw  this  and  the  vein 
which  is  immediately  below  outward,  and  the  artery  will  be  seen  deeply 
situated,  and  in  the  upper  part  of  the  space  internal  to  the  vein.  Lower 
down  the  relations  change,  the  nerve  crossing  superficial  to  the  vein, 
and  this  overlying  the  artery  (Fig.  304). 

Ligation  of  the  Posterior  Tibial  Artery  at  the  Middle  of  the  Leg. — 
Make  an  incision,  half  an  inch  from  and  parallel  with  the  ianer  margin  of 
the  tibia,  three  inches  and  a  half  long.    Avoid  the  internal  saphenous  vein. 

After  passing  the  deep  fascia, 
look  for  the  lower  tibial  fibers 
of  the  soleus,  which  i)ass  ob- 
liquely from  this  border  of  the 
tibia  backward  and  slightly 
downward.  Divide  these  on  a 
director,  and  with  the  finger 
separate  the  sural  from  the 
flexor  muscles.  Retracting  the 
edges  of  the  wound,  the  artery 
will  be  seen,  with  a  vein  on 
either  side  and  the  posterior 
tibial  nerve  lying  Just  behind. 
The  vessels  are  held  down  by 
the  common  sheath  of  the  deep 
muscles  (Fig.  305). 

Opposite  the  AnJcle- Joint . — 
Half  way  from  the  tip  of  the 
internal  malleolus  to  the  ante- 
rior edge  of  the  tendo  Achillis 
commence  an  incision,  which 
extends  directly  upward  for  one 
inch  and  a  half.  Dividing  the 
skin  and  fascia  upon  a  director, 
cut  the  dense  internal  annular 
ligament.  The  artery,  with  its 
two  veins,  will  be  found  with 
the  posterior  tibial  nerve  and 


Fig.  305. — Ligatiou  of  the  posterior  iibml  above  the  malleoluo. 

tendon  of  the  flexor  longus  poUicis  behind,  and  the  flexor  longus  digito- 
rum  and  tibialis  posticus  in  front.     As  the  artery  curves  around  the  mal- 


LIGATION    OF   ARTERIES. 


273 


leolus  it  will  be  found 
one  third  the  distance 
from  the  tip  of  the  mal- 
leolus to  the  convexity 
of  the  heel. 

The  Anterior  Tibial 
at  tlie  Middle  of  the  Leg. 
— A  line  from  a  point 
half  way  between  the 
anterior  tuberosity  of 
the  tibia  and  the  head 
of  the  fibula  to  a  like 
point  between  the  two 
malleoli,  in  front  of  the 
ankle,  will  indicate  the 
position  of  this  artery. 
At  the  middle  of  the 
leg  make  a  four-inch 
incision  in  this  line,  di- 
viding everything  down 
to  the  dense  fascia  im- 
mediately over  the  mus- 
cles. Split  this  on  a  di- 
rector and  dissect  it  up 
carefully,  searching  for 
the  interspace  between 
the  tibialis  anticus  in- 
ternally and  the  exten- 
sor proprius  pollicis  ex- 
ternally. Finding  this, 
discard  the  knife,  and 
with  the  finger  separate 
the  muscles,  and  the  ar- 
tery, veins,  and  nerve 
will  be  found  deep  down 
upon  the  interosseous 
membrane,  the  nerve  be- 
ing external  and  slight- 
ly in  front,  and  the 
veins  wound  about  the 
artery.  In  order  to  re- 
lax the  muscles  and  ad- 
mit the  light,  flex  the 
tarsus  on  the  leg  (Fig. 
306). 

At  the  Lower  Por- 
tion.— One  inch  above 
the  tip  of  the  internal 


Fig.  306.— Ligation  of  the  anterior  tibial  in  the  middle  and  lower 
third°of  the  leg,  and  of  the  dorsalis  pedis  artery. 


274  A  TEXT-BOOK   ON   SURGERY. 

malleolus  begin  an  incision,  and  carry  it  two  inches  upward,  in  the  tibial 
line  above  given.  This  incision  is  along  the  fibular  border  of  the  exten- 
sor pollicis,  between  w-hich  and  the  tendon  of  the  extensor  communis 
digitorum  the  artery  will  be  found,  with  the  nerve  on  the  fibular  side, 
and  its  companion  veins  on  either  side. 

The  Dor  salts  Pedis. — One  fourth  of  an  inch  to  the  fibular  side  of  and 
parallel  with  the  tendon  of  the  extensor  pollicis  make  an  incision,  one 
inch  long,  over  the  tarsus.  The  artery  and  veins  will  be  seen  on  a  plane 
slightly  deeper  than  the  tendon,  with  the  nerve  on  the  tibial  side  of  the 
vessels.  This  line  is  a  continuation  upward  of  the  first  metacarpal  inter- 
space (Fig.  306). 


CHAPTER  XII. 

THE   SUEGICAL   DISEASES   AST)   SUKGEET   OF  THE   BOXES. 

Ostitis. — Inflammation  in  bone  may  be  acute  or  chronic,  general  or 
circmnscribed,  traumatic  or  idiopatliic.  It  may  involve  the  periosteum 
{periostitis),  the  compact  and  cancellous  substance  (ostitis),  and  me- 
dulla (endostitis  or  osteo-myelitis).  Endostitis  and  periostitis  may 
occur  independently,  yet  ostitis,  more  or  less  severe,  must  of  necessity 
be  a  part  of  a  pronounced  inflammation  of  either  the  peiiosteum  or  the 
endosteum  and  medulla. 

The  termination  of  inflammation  in  bone  is  in  resolution  or  local 
death.  In  resolution  the  inflammatory  embryonic  tissue  undergoes 
granular  metamorphosis  and  is  absorbed,  or  it  may  be  in  part  converted 
into  new  bone.  If  the  bone  dies,  it  may  be  cast  off  as  a  sequestrum,  or 
remain  imprisoned  in  a  shell  of  new-made  osseous  tissue,  the  inrolucrum. 

"When  the  inflammatory  process  is  severe,  or  the  arrest  of  nutrition 
sudden  and  complete,  necrosis,  or  death  in  mass,  occui's ;  under  other 
and  milder  conditions  of  death  in  bone,  the  process  of  dissolution  is 
known  as  caries. 

In  necrosis,  which  is  aptly  compared  to  gangrene  of  the  soft  tissues, 
the  cast-off  portion  retains  something  of  its  original  form  and  character  ; 
in  caries,  which  is  the  molecular  death,  or  ulceration  of  bone,  the  cell- 
elements  disappear  by  granular  degeneration,  leaving  no  trace  of  the 
original  sti'ucture. 

Pathology. — When  a  bone  is  subjected  to  irritation  by  a  force  ajjplied 
from  \vithout,  or  an  interference  with  its  normal  process  of  nutrition 
from  within,  the  earliest  change  which  occurs  is  hyper(Bniia,  with  marked 
increase  in  the  niimber  of  white  blood-corpuscles.  With  the  dilatation 
of  the  blood-vessels,  and  escape  of  the  leucocytes  into  the  extra-vascular 
spaces,  cell-activity  becomes  general.  Rapid  jjroliferation  occurs  in  the 
ceUs  of  the  periosteum  ;  the  meduUo-ceUs  and  the  myeloplaxes,  found 
not  only  in  the  central  maiTow,  but  around  the  vessels  in  the  Haversian 
canals ;  the  connective- tissite  cells  and  the  bone-corpuscles.  The  result 
of  this  general  proliferation  is  a  mass  of  protoplasm  or  embryonic  cells 
analogous  to  that  described  in  the  chapter  on  Inflammation. 

Coincident  with  the  formarion  of  this  embryonic  tissue,  absorption  of 
the  surrounding  and  contiguous  osseous  lamellge  occurs,  giving  rise  to 
abnormal,  and  often  multiple  and  communicating,  cavities,  known  as  the 


276  A  TEXT-BOOK  ON   SURGERY. 

caverns  of  HoiosMp.  The  cause  of  this  absorption  can  not,  as  yet,  be 
satisfactorily  explained. 

Up  to  this  point  in  the  process  of  inflammation  the  progress  is  practi- 
cally the  same  in  all  forms  of  ostitis,  whether  acnte  or  chronic,  traumatic 
or  idiopathic. 

If  the  ostitis  is  mild  in  character,  and  the  tissues  involved  are  in 
proper  condition  to  resist  disease,  a  portion  of  the  mass  of  embryonic 
cells  disappears  by  absorption,  while  the  remainder  becomes  converted 
into  new  bone,  which  new  formation  is  compensatory  to  the  loss  of  tissue 
in  the  earlier  stages  of  the  inflammation.  This  result  may  occur  in  the 
periosteum,  compact  tissue,  or  endosteum. 

In  exceptional  cases  the  process  of  embryonic  tissue-formation  and 
absorption  of  the  lamellse  goes  on  indefinitely  until  the  bone  is  more  or 
less  completely  destroyed  and  replaced  by  granulation-tissue.  This  va- 
riety is  known  as  rarefying  ostitis  (ostitis  rarefaeiens). 

When,  in  the  process  of  repair,  the  new  formation  of  bone-tissue  is  in 
•excess  of  the  original  structure,  it  is  terifled  productive  ostitis  {ostitis 
osteoplastica).  In  some  of  these  new  formations  or  exostoses  the  osseous 
structure  resembles  closely  the  parent  bone,  while  in  others  the  new 
product  is  more  dense  and  eburnated.  To  this  variety  the  name  of  ostitis 
sclerosa  has  been  given. 

Productive  ostitis  and  ostitis  sclerosa  occur  usually  in  the  bones  of 
the  cranium  and  in  the  compact  substance  of  the  long  bones.  In  rare 
instances  the  meduUary  cavity  is  filled  with  newly  formed  bone.  If  the 
inflammatory  process  is  intense,  and  the  condition  of  the  tissues  favorable 
to  its  development,  not  only  the  compact  substance,  but  the  medulla  and 
cancellous  tissue  becomes  rapidly  infiltrated  with  pus,  inducing  a  more 
or  less  extensive  necrosis.  This  condition  is  termed  osteo-myelitis.  Sup- 
puration is  especially  apt  to  occur  in  ostitis  affecting  the  spongy  bones, 
as  those  of  the  tarsus  and  carpus,  the  terminations  of  the  long  bones,  and 
the  bodies  of  the  vertebrae,  although  cases  are  not  infrequently  observed 
in  which  the  embryonic  granulation-tissue  has  filled  the  space  formerly 
occupied  by  the  spongy  substance,  and  in  which  no  pus  is  present  {ostitis 
interna  fungosa).  The  inflammatory  tissue  occasionally  undergoes 
caseous  degeneration  {ostitis  interna  caseosa).  It  is  the  opinion  of  mod- 
ern pathology  that  a  large  proportion  of  cases  of  ostitis  and  osteo-mye- 
litis not  of  traumatic  origin  are  due  to  the  presence  of  the  bacillus  tuber- 
ciilosis  {tubercular  ostitis). 

Causes. — Inflammation  of  the  periosteum  and  the  underlying  bone 
may  result  from  direct  or  indirect  violence.  A  fracture  will  produce  a 
typical  acute  ostitis,  while  the  same  result  may  be  secondary  to  an  injury 
of  a  joint.  Traumatic  ostitis  is  almost  always  acute,  while  idiopathic 
inflammation  is  usually  subacute  in  character.  Ostitis  and  periostitis 
occur  chiefly  as  expressions  of  a  dyscrasia.  They  are  frequently  met 
with  in  patients  suffering  from  tuberculosis,  scrofula,  and  syphilis.  Peri- 
ostitis osteoplastica,  affecting  the  tibia  and  bones  of  the  calvarium,  re- 
sulting in  nodes  or  exostoses,  is  frequent  in  this  last  disease.  Tubercu- 
losis in  bone  usually  occurs  in  the  young,  and  naturally  in  children  of 


THE  SURGICAL  DISEASES.  277 

tubercular  parentage.  The  vertebrae,  ribs,  and  sternum  are  more  apt  to 
be  attacked,  and  next  in  order  are  the  tibia  and  femiy.  In  these  bones 
the  tuberculous  deposit  is  usually  found  at  or  near  the  epiphysis,  the 
joint  becoming  affected  by  direct  invasion  through  the  articular  surfaces  ; 
less  frequently  the  bone  is  involved  by  invasion  from  the  joint  (tuber- 
cular synovitis  or  arthritis). 

In  traumatic  ostitis  it  is  probable  that  the  initial  lesion,  in  the  great 
majority  of  instances,  is  the  rupture  of  a  capillary,  and  hsemorrhage  in 
the  cancellous  tissue.  It  has  been  shown  by  Cornil  and  Ranvier  that 
the  protection  of  the  capillaries,  in  bone  which  is  undergoing  active  de- 
velopment, is  so  deficient  that  extravasation  occurs  wdth  such  frequency 
that  the  process  may  be  almost  considered  as  physiological.  This  is 
especially  true  of  the  short,  spongy  bones,  the  epiphyseal  regions  of  the 
long  bones,  the  sternum,  and  vertebrae.  If  to  this  be  added  the  fact  that 
these  bones  are  the  most  frequent  seat  of  the  inflammatory  change,  and 
that  the  j)eriod  of  life  in  which  ostitis  usually  occurs  is  tlie  jjeriod  of 
greatest  nutritive  activity,  it  is  not  diSicult  to  conceive  that  an  extrava- 
sation of  blood  which  would  be  practically  harmless  in  a  vigorous  and 
healthful  condition  of  tlie  bones  might  induce  serious  inflammatory 
changes  in  tissues  already  deficient  in  nutrition. 

Symptoms. — Periostitis,  whether  acute  or  chronic,  is  usually  charac- 
terized by  pain  at  the  seat  of  inflammation  before  any  tumefaction  is  rec- 
ognized. The  severity  of  the  pain  is  in  proportion  to  the  intensity  of  the 
morbid  process.  It  is  markedly  increased  on  pressure,  and  is  usually 
more  severe  at  night.  The  symptoms  of  pressure  upon  the  end-organs 
of  the  sensory  nerves  are  coincident  with  the  remarkably  rapid  develop- 
ment of  the  embryonic  tissue  from  proliferation,  chiefly  of  the  cells  of 
the  periosteum,  the  new  formation  lifting  the  covering  from  the  bone. 
The  disease  may  be  ushered  in  with  or  without  a  chill  or  rigors.  The 
exacerbations  of  temperature  are,  as  a  rule,  not  so  high  in  osteo-perios- 
titis  as  in  osteo-myelitis. 

In  this  latter  fonn  of  ostitis  the  symptoms  are  more  grave  in  charac- 
ter. The  sense  of  pain  is  deep-seated  and  intense  in  most  instances,  with 
usually  high  febrile  movement.  The  surrounding  soft  parts  become 
swollen,  red,  and  cedematous,  and,  as  a  rule,  septic  absorption  becomes, 
in  the  early  history  of  the  case,  a  prominent  and  dangerous  symptom, 
terminating  not  infrequently  in  pyaemia  and  death. 

Treatment. — The  earliest  indication  in  the  treatment  of  acute  perios- 
titis is  rest  in  bed,  with  the  part  involved  in  the  position  of  least  discom- 
fort. Hot  applications,  by  means  of  the  rubber  water-bag,  or  cloths 
dipped  in  hot  water  and  partially  wrung  out,  or  the  cold  ice-bag  or 
cloths,  as  may  seem  most  agreeable  to  the  patient,  will  be  found  of  value. 

When  the  inflammatory  symptoms  are  severe,  as  determined  by  pain, 
swelling,  and  high  febrile  movement,  and  especially  when  the  suspicion 
of  pus  under  the  jDeriosteum  has  been  confirmed  by  exploration  with  a 
good-sized  hypodermic  needle  and  aspirator,  a  free  incision  is  demanded. 
This  procedure  should  not  be  delayed,  for  not  infrequently  irreparable 
damage  may  follow  the  lifting  of  the  periosteum  by  the  inflammatory 


278  A  TEXT-BOOK  ON   SURGEKY. 

process.  It  is  better  to  err  on  the  safe  side,  if  the  diagnosis  is  in  doubt, 
and  malie  the  incision  down  and  through  to  the  bone,  an  operation  which 
is  exceedingly  simple  when  Esmarch's  bandage  is  employed,  and  practi- 
cally free  from  danger. 

All  such  wounds  should  be  filled  with  sublimate-gauze  dressings. 
When  ostitis  exists,  if  the  symptoms  point  to  severe  or  extensive  inflam- 
mation, the  trephine,  rongeur,  gouge,  or  chisel  should  be  freely  used  to 
effect  easy  escape  to  any  pus  which  may  be  imprisoned  in  the  bony 
tissues.  In  osteo-myelitis  this  method  of  treatment  is  imperative.  Ab- 
scess of  bone  should  be  treated  upon  the  principles  of  immediate  opera- 
tion and  free  drainage. 

When  necrosis  or  caries  is  evident,  the  removal  of  the  dead  tissue  is 
necessary,  since  its  presence  as  a  foreign  body  is  a  constant  menace  to 
the  contiguous  healthy  structures.  A  free  incision  should  be  made,  down 
to  and  along  the  diseased  line,  the  first  and  only  cut  going  down  to  the 
dead  bone,  dividing  the  thickened  periosteum  with  the  skin.  Then,  with 
the  elevator — preferably  Sayre's  oyster-knife — carefully  peel  up  the  peri- 
osteum until  the  healthy  bone  is  reached.  If  the  dead  bone  can  not  be 
lifted  out  it  should  be  divided  with  the  exsector  or  the  cutting-forceps. 
For  lifting  a  sequestrum  the  forceps  of  Hamilton  or  other  grasping  in- 
strument will  suffice.  In  chronic  ostitis  of  the  spongy  substance  Volk- 
mann's  spoon-scraper  is  an  excellent  instrument. 

In  no  department  of  surgery  is  thoroughness  more  essential  than  in 
operations  upon  carious  and  necrotic  bone,  and  especially  in  osteo-mye- 
litis. The  part  involved  should  be  exposed  by  a  very  free  incision,  when 
this  is  possible,  and  all  diseased  portions  removed  with  the  sharp  spoon 
or  chisel  or  gouge.  When  an  extremity  is  involved,  Esmarch's  bandage 
should  be  used.  In  applying  it,  no  compression  should  be  exercised 
over  the  area  of  inflammation,  for  fear  of  forcing  septic  products  into  the 
vessels.  In  the  tibia,  after  the  periosteum  has  been  lifted  and  the  soft 
parts  held  aside,  the  anterior  aspect  of  the  bone  should  be  chiseled  off 
with  the  curved  instrument  until  the  medullary  canal  as  far  as  diseased 
has  been  converted  into  a  trough,  the  sides  and  bottom  of  which  should 
be  most  thoroughly  scraped  with  a  Volkmann's  spoon. 

In  all  these  cases  sublimate  irrigation  is  essential,  and  in  tuberculosis 
of  bone,  in  order  to  prevent  possible  systemic  infection,  it  is  imperative. 
With  the  tourniquet  applied,  a  1  to  2,000  solution  may  be  used  either 
continuously  or  by  freely  flooding  the  wound  at  very  frequent  intervals. 
In  order  to  insure  the  destruction  of  all  germs,  the  wound  may  be  finally 
filled  and  mopped  out  with  a  1  to  500  solution  ;  but  this  should  be 
immediately  diluted  by  washing  out  with  the  weaker  solution.  When 
no  tourniquet  is  employed,  the  solution  should  not  be  stronger  than  1 
to  3,000,  usually  1  to  5,000. 

When  one  portion  of  the  canal  of  the  tibia  is  involved  it  is  impera- 
tive to  expose  the  medulla  well  above  and  below  this  point  in  ox'der  to 
allow  of  full  inspection,  and  in  most  cases  it  will  be  necessary  to  trougJi 
the  entire  canal  to  each  epiphysis.  When  the  disease  extends  through 
the  epiphyses  the  cancellous  expansions  should  be  scraped  out. 


THE   SURGICAL  DISEASES.  279 

When  a  bone  is  tlius  troughed  it  should  be  packed  with  aseptic 
gauze  and  treated  by  the  open  method.  No  sutures  are  used  and  no 
ligatures  are  required.  Hsemorrhage  is  controlled  by  compression  over 
the  dressing  and  by  elevation  of  the  member.  The  dressings  usually 
require  renewing  about  once  every  five  or  seven  days.  When  sinuses  in 
the  soft  parts  exist  they  should  be  thoroughly  scraped  out  or  dissected 
away  and  carefully  asepticised  with  sublimate  solution. 

When  the  lower  end  and  cancellous  expansion  of  the  femur  is  in- 
volved and  the  joint  not  yet  invaded,  it  should  be  entered  from  the 
lateral  aspects  (preferably  the  external),  in  order  to  avoid  the  synovial 
cavity  beneath  the  quadriceps  tendon  which  extends  two  inches  or  more 
above  the  articular  surface. 

The  same  general  rules  apply  to  all  the  long  bones.  In  the  hands  and 
feet  the  sharp  spoon  will  iisually  suffice.  Multiple  drainage-tubes  are 
often  essential  in  these  cases. 

Osteomalacia — Rachitis. — Osteomalacia  {moUifies  ossiuvi)  is  a  dis- 
ease of  adult  life,  and  is  especially  apt  to  occur  in  child-bearing  women. 
The  chief  pathological  change  is  the  disappearance  of  the  earthy  con- 
stituents from  the  bones,  and  their  presence  in  the  blood  and  excretions 
in  abnormal  proportion.  Softening  is  often  present  to  such  an  extent 
that  marked  distortions  occur  from  muscular  contraction  and  superin- 
cumbent weight.  The  medulla  of  the  bones  is  the  seat  of  congestion, 
often  resulting  in  extravasation  of  blood.  In  the  later  stages  the  bony 
lamellse  disappear  by  absorption,  the  process  commencing  from  within. 

The  treatment  consists  in  the  prevention  of  fracture  and  deformity  by 
proper  precaution,  and  the  restoration  of  the  osseous  system  to  its  normal 
condition  by  generous  diet,  studied  hygiene,  tonics,  and  the  administra- 
tion of  the  hypophosphites  of  lime  and  soda,  with  cod-liver  oil  and  iron. 

Sachitis,  or  ^'rickets,"  is  strictly  a  disease  of  childhood  and  youth. 
Although  it  attacks  the  entire  osseous  system,  its  disastrous  effects  are 
chiefly  observed  in  the  bones  of  the  skull  and  the  long  bones  of  the 
lower  extremities.  The  bones  of  the  skull  become  thickened  and  promi- 
nent, the  sternum  is  advanced  and  angular  ("pigeon-breast"),  and  the 
bones  of  the  lower  extremities  are  curved  antero-posteriorly  or  laterally. 
While  the  diameter  of  a  rachitic  bone  is  usually  increased  at  all  points, 
the  enlargement  is  most  marked  near  the  extremities.  Rickets  is  a  dis- 
ease of  malnutrition.  Its  chief  pathological  feature  is  the  formation  of 
an  embryonic  tissue,  which  in  normal  condition  is  converted  into  bone, 
but  in  the  rachitic  diathesis  only  partially  (if  at  all)  undergoes  ossi- 
fication. The  cells  of  the  periosteum  are  unusually  active  in  this  pro- 
liferation, as  are  the  cartilage  bone-making  cells ;  yet  this  new  tissue 
remains  in  great  part  embryonic,  without  the  formation  of  the  osseous 
lamellae. 

The  treatment  of  rickets  is,  first,  to  prevent  deformity,  and,  secondly, 
to  relieve  the  dyscrasia.  Rachitic  children  should  be  kept  in  the  recum- 
bent posture,  or,  if  allowed  to  stand  or  walk,  artificial  support  should  be 
given  to  the  lower  extremities  and  spine.  The  medical  indications  are 
nutritious  diet,  out-of-door  life,  and  the  administration  of  the  hypophos- 


280  A  TEXT-BOOK   ON   SURGERY. 

pMtes  of  lime  and  soda,  with  cod-Jiver  oil  and  tonics.  The  correction  of 
the  deformities  which  may  result  from  rickets  will  be  considered  in  the 
article  on  Orthopajdic  Surgery. 

Fractures. 

Fractures. — A  fracture  is  a  sudden  solution  of  continuity  in  bone  or 
cartilage.  The  term  is  commonly  applied  to  lesions  of  bone.  A  fracture 
may  be  partial  or  complete  ;  transverse,  oblique,  or  longitudinal ;  single, 
double,  or  multiple ;  simple,  comminuted,  compound,  and  complicated. 
A  partial  fracture  occurs  when  a  bone  breaks  or  splinters  on  one  side  (its 
convex  surface)  and  bends  on  the  opposite  (green-stick  fracture).  In  a 
complete  fracture  there  is  a  total  solution  of  continuity.  A  transverse 
fracture,  or  one  in  which  the  line  of  cleavage  is,  in  general,  at  a  right 
angle  with  the  axis  of  the  bone,  is  rare  as  compared  with  the  oblique.  A 
longitudinal  fracture  is  a  split  in  the  long  axis  of  a  bone.  It  is  frequently 
caused  by  penetrating  wounds  (gunshot),  or  may  result  from  a  fall  with 
great  violence  upon  the  hands  or  feet,  when  the  cleavage  commences  in 
the  articular  surface.  In  this  way  the  astragalus  may  be  driven  between 
the  fragments  of  a  longitudinal  fracture  of  the  tibia,  or  a  like  accident 
occur  at  the  knee  or  wrist. 

A  single  fracture  is  one  break  in  one  bone  ;  a  double  fracture  is  a  so- 
lution of  normal  continuity  in  two  bones  of  one  member,  as  the  ulna  and 
radius,  the  tibia  and  fibula ;  multijile  fracture  is  a  term  applied  to  two 
or  more  separate  breaks  in  one  or  several  bones.  When  a  bone  is  broken 
in  one  direction,  and  at  one  point,  without  injury  of  any  surrounding 
organ  or  perforation  of  the  skin,  it  is  termed  a  simple  fracture  ;  if  there 
are  more  than  two  fragments  it  is  a  comminuted  fracture  ;  if  any  part  of 
the  fractured  surface  communicates  with  the  atmosphere  it  is  a  com- 
pound ;  and  if  it  communicates  with  a  joint,  or  involves  in  the  fracture 
the  wound  of  any  important  organ,  as  a  large  artery  or  vein,  or,  as  in 
fracture  of  a  rib,  occasionally  the  pleura  or  lung  is  wounded,  it  is  a  com- 
plicated fracture.  An  impacted  fracture  is  one  in  which  the  fragments 
are  splintered  and  interlocked  with  more  or  less  complete  immobility. 

A  fracture  may  be  caused  by  external  violence,  directly  or  indirectly 
apj)lied,  or  by  muscular  action,  or  both  factors  may  unite  in  the  produc- 
tion of  the  lesion.  As  an  exami)le  of  direct  violence,  in  the  effort  to  ward 
off  a  blow  from  the  head  the  ulna  may  be  broken  by  the  force  of  a  cane 
immediately  beneath  the  contusion  of  the  soft  parts.  A  blow  on  the 
vertex  which  fractures  the  base  of  the  skull,  or  a  fall  on  the  foot  which 
breaks  the  femur,  are  common  examples  of  fracture  from  indirect  vio- 
lence. Contraction  of  the  quadriceps  extensor  may  fracture  the  patella, 
or  the  same  lesion  may  result  from  a  fall  on  the  knee,  in  which  the  direct 
violence  and  the  action  of  this  powerful  muscle  unite  to  cause  the  fracture. 
In  addition  to  these  direct  agencies,  certain  conditions  of  the  tissues  pre- 
dispose to  fracture.  The  bones  of  the  aged  break  more  readily  and  are 
slower  in  repair  than  the  young  and  middle-aged.  There  is  a  not  infre- 
quent condition  of  fragility  in  the  bones  of  the  insane  which,  either  alone 


FRACTURES.  281 

or  together  with  excessive  aud  uncontrollable  muscular  action,  renders 
them  liable  to  break.  I  have  seen  one  specimen  of  this  nature  in  which 
every  rib  was  broken,  and  some  of  these  in  two  or  more  places.  As  hereto- 
fore stated,  fracture  is  common  in  the  disease  known  as  osteomalacia, 
and  may  occur,  though  less  likely,  in  rachitis.  Sex,  vocation,  and 
manual  preference  also  predispose  to  fractiire.  Men  suffer  much  more 
frequently  than  women,  and  any  vocation  which  exposes  to  violence 
increases  the  proportion  of  fractures.  The  bones  of  the  right,  the  pre- 
ferred side,  are  more  frequently  broken  than  the  left. 

Symptoms. — The  symptoms  of  fracture  are:  Loss  of  function  ;  ab- 
sence of  normal  contour  ;  'preternatural  mobility ;  crepitus.  A  broken 
bone  which  is  not  impacted  no  longer  acts  as  a  support,  or  sustains  mus- 
cular contraction.  The  natural  shape  or  outline  is  more  or  less  distorted 
by  displacement  and  overlapping  of  the  fragments.  Careful  manipula- 
tion will  detennine  the  overriding,  measurement  ■nill  show  shortening, 
while  comparison  with  the  uninjured  side  will  determine  the  degree  of 
asymmetry. 

Crepitus.,  which  is  not  always  necessary  to  correct  diagnosis,  is  the 
sensation  imparted  to  the  touch,  and  occasionally  recognized  by  the  ear, 
when  the  rough  fragments  are  moved  so  as  to  grate  upon  each  other. 
The  diagnosis  of  an  impacted  fracture  is  more  difficult,  since  crepitus  and 
mobility  are  absent.  Shortening  must  of  necessity  exist,  which,  with 
partial  loss  of  function  and  more  or  less  pain  and  thickening  at  the  point 
of  fracture,  will  lead  to  the  recognition  of  the  lesion.  A  longitudinal 
fracture  or  fissure  is  often  with  difficulty  recognized,  and  may  escape 
detection. 

Process  of  Repair. — The  first  and  immediate  result  of  a  fracture  is 
hsemorrhage,  which  occurs  from  the  arteries,  arterioles,  capillaries, 
venules,  and  veins  of  the  medulla,  compact  substance,  periosteum,  and 
any  surrounding  soft  parts  which  may  be  involved  in  the  injury.  As  a 
result  of  the  irritation  determined  by  the  accident  and  heemorrhage,  in- 
flammation is  precipitated.  Hypereemia  of  the  bone  and  contiguous  soft 
tissues  ensues.  As  in  ostitis,  absorption  of  the  bony  walls  of  the  Haver- 
sian canals  occurs  with  the  dilatation  of  the  vessels,  and  general  cell-pro- 
liferation follows.  In  tlie  medullary  cavity  proper,  in  the  medullary 
spaces  of  the  Haversian  systems,  in  the  periosteum,  and  the  inflamed 
surrounding  tissues,  this  process  is  common.  As  in  all  inflammatory 
processes,  the  leucocytes  are  present  in  great  numbers.  The  medullo- 
cells,  myeloplaxes,  osteoblasts,  periosteal  cells,  and  connective-tissue 
corpuscles,  undergo  rapid  proliferation,  resulting  in  the  formation  of  a 
mass  of  common  embryonic  cells,  which  infiltrate  the  clot  between  and 
around  the  fragments.  K'ew-formed  capillaries  are  projected  into  and 
through  this  granulation-tissue  in  the  same  manner  as  in  the  jorocess  of 
rej)air  in  wounds  of  the  soft  parts. 

If  the  broken  ends  do  not  come  in  contact  with  the  air — that  is,  if  the 

fracture  is  not  compound — the  process  of  repair  in  bone  after  an  injury 

is  similar  to  the  physiological  process  of  development  of  this  tissue — 

namely,  the  embryonic  tissue  is  developed  into  cartUage-cells,  and  these, 

18* 


282 


A  TEXT-BOOK   ON  SURGERY. 


undergoing  proliferation,  develop  into  a  secondary  embryonic  tissue, 
which  is  formed  directly  into  bone.  If,  however,  air  is  admitted  to  a 
wound  in  bone,  the  process  of  ossification  in  the  embryonic  tissue  is  more 
rapid  and  direct,  since  the  intermediate  stage  of  cartilage-cell  formation 
does  not  occur. 

A  portion  of  this  new-formed  tissue,  which  results  from  the  irritation 
following  a  fracture,  undergoes  a  process  of  calcification  by  the  absorp- 
tion of  inorganic  material  from  the  blood,  and  is  then  known  as  callus. 
That  portion  which  lies  around  and  on  the  outer  side  is  the  enslieafhing 
callus  ;  between  the  fragments,  the  intermediate ;  and  within  the  medul- 
lary canal,  the  central  or  '■'■pin''''  callus. 

In  an  adult  or  middle-aged  person,  commencing  within  the  first  few 
hours  succeeding  a  fracture,  the  embryonic  tissue,  which  is  formed  in 
varying  quantity,  remains  soft  and  yielding  until  about  the  tenth  day, 
when  the  cells  begin  to  be  infiltrated  with  calcareous  matter.  The  pro- 
cess of  solidification  in  the  callus  is  complete  at  a  jDeriod  varying  usually 
from  fifteen  to  thirty  days.  It  is  more  rapid  in  children,  and  slower 
in  the  old. 

When  complete  displacement  with  overlapping  occurs,  or  when  an 
aponeurosis  or  tendon,  or  other  dense  tissue,  separates  the  broken  ends, 
the  process  of  callus-building  is  interfered  with,  and  failure  of  ossification 
may  result.     Usually  a  greater  portion  of  the  callus  becomes  absorbed 


Fig.  307. — LoDgitudin.il  section  of  a  fractured  femur,  show- 
ing permanent  occlusion  of  the  medullary  canal.  The 
stalactite  exostosis  is  well  shown  in  the  right-hand 
figure.     (From  a  specimen  of  the  author's.) 


Fig.  303. — Permanent  thickening  from 
new-formed  bone  in  a  fractured 
humerus.  (From  a  specimen  of 
the  author's  in  the  Wood  Museum. ) 


FRACTURES. 


283 


within  from  thirty  to  sixty  days  after  the  fracture.  This  is  especially 
true  of  the  ensheathing  layer  and  the  central  caUus.  That  portion  which 
intervened  between  the  opposing  surfaces  becomes  organized  into  per- 
manent bone.  The  pin  callus  remains  for  a  while,  and  may  completely 
occlude  the  medullary  canal,  but  usu- 
ally at  a  later  period  undergoes  ab- 
sorption. In  some  cases  the  medul- 
lary canal  is  not  re-established.  Fig. 
307  shows  a  section  of  a  broken  femur 
in  which,  after  a  considerable  lapse  of 
time,  the  canal  was  still  occluded. 
The  j^eculiar  stalactite  (exostosis)  oc- 
curred at  the  seat  of  fracture.  The 
permanency  of  the  external  callus  and 
its  development  into  exostoses  de- 
pends chiefly  upon  the  disturbed  nu- 
trition of  the  part  (Fig.  308).  It  has 
been  noticed  that  when  a  fracture  oc- 
curs near  the  insertion  of  a  group  of 
muscles  (as  at  or  near  the  trochanter), 
exostosis  is  the  rule,  and  may  be  very 
extensive  (Fig.  308  a). 

Prognosis  and  Treatment  in  Gen- 
eral.— The  prognosis  of  a  simple  fract- 
ure in  a  healthy  child  or  adult  is 
always  favorable.  The  danger  is  in- 
creased with  the  multiplicity  and  com- 
plications of  the  accident.  A  com- 
pound fracture  is  sufficiently  grave  to 
demand  the  greatest  attention.  Death 
may  result  from  sepsis  or  fatty  embol- 
ism. A  longitudinal  fracture  is  a  more 
serious  injury,  especially  grave,  as  far 
as  the  integrity  of  the  member  is  con- 
cerned, when  a  joint  is  implicated. 

In  all  forms  of  fracture  the  progno- 
sis increases  in  gravity  with  each  decade  beyond  the  third.  When  the 
fracttire  is  complete,  and  displacement  has  occurred,  exact  reposition 
is  impossible,  and  shortening  almost  inevitable.  The  exceptions  are 
extremely  rare,  especially  in  the  single  bones,  as  the  femur,  humerus, 
and  clavicle. 

The  great  end  to  be  achieved  in  the  treatment  of  fractures  is  a  re- 
duction of  the  displacement  to  as  near  the  normal  as  possible,  and  the 
absolute  retention  of  the  parts  as  replaced.  Reduction  may  usually  be 
accomplished  without  an  anaesthetic,  but  where  the  overlapping  is  con- 
siderable, and  muscular  contraction  and  rigidity  marked,  ether  narcosis 
should  be  secured.  The  comparative  safety  of  this  anaesthetic  justifies 
its  general  employment  in  fractures.     A  compound  fracture  demands. 


Fig.  308  i. — Case  of  I.  J.  Liclitenberg.  Show- 
ing condition  of  femur  twenty-nve  years 
after  gunsliot-fraeture  (at  "the  Wilder- 
ness," 1864).  At  a,  sequestrum  pro.iecting 
from  center  of  shaft.  Two  small  particles 
of  lead  may  be  seen  imbedded  at  tne  edge 
of  the  openinfT.  Numerous  exostoses.  Am- 
putation done  January  8,  1889. 


284 


A  TEXT-BOOK  ON  SURGERY. 


with  fixation,  free  drainage.  The  fragments  should  be  reduced,  even 
when  it  is  necessary  to  remove  projecting  ends  with  the  forceps  or  saw 
to  effect  this.  Once  placed  in  position,  they  should  be  kept  at  rest,  with 
openings  and  counter-openings.  The  various  methods  of  treatment  will 
be  described  with  each  fracture. 

Special  Fractures — Cranium.— The  bones  of  the  skull  may  be  fract- 
ured by  direct  or  indirect  violence.  Direct,  when  the  bones  give  way 
immediately  beneath  the  point  which  is  struck ;  indirect,  as  when,  by 
falling  from  a  height  and  striking  on  the  feet  or  buttocks,  the  base  of 
the  skull  is  fractured  by  the  force  transmitted  through  the  vertebral  col- 
umn. A  rarer  form  of  indirect  fracture  of  the  skull  is  that  known  as 
fracture  by  contre-coup,  in  which  the  bones  give  way  at  a  point  opposite 
to  that  at  which  the  injury  is  received. 

Fractures  of  the  skull  may  occur  with  or  without  compression  of  the 
brain  or  meninges.  The  outer  table  may  be  depressed  by  crushing  into 
the  diploe  without  fracture  of  the  inner  or  vitreous  table,  and,  strange  as 
it  may  appear,  in  rare  instances  the  inner  table  is  broken,  while  the  outer 
plate  is  not  depressed.  More  frequently  both  tables  are  involved. 
Fractures  of  the  skull  may  be  simple,  compound,  comminuted,  corajDli- 
cated,  single,  or  multiple.  They  are  chiefly  divisible  into  those  of  the 
vertex  and  those  of  the  base. 

Fractures  of  the  base  are  usu- 
ally due  to  indirect,  those  of  the 
vault  to  direct,  violence.  A  blow 
on  the  top  of  the  head  may  pro- 
duce a  fracture  only  at  the  base,  or 
at  both  the  apex  and  base.  Usu- 
ally the  break  occurs  at  a  point  di- 
rectly in  the  line  of  the  force  which 
causes  the  lesion.  Aran  demon- 
strated, by  dropping  cadavers  from 
a  height,  that  when  the  frontal  re- 
gion received  the  blow  the  fracture 
usually  took  place  in  the  anterior 
fossa,  the  middle  parietal  and  the 
occipital  region  giving  the  key  to  a 
fracture  respectively  in  the  middle 
and  posterior  fossae.  A  blow  on 
the  chin  has  been  known  to  pro- 
duce a  fracture  by  driving  the  in- 
ferior maxilla  against  the  temporal 
bone.  A  fall  on  the  buttocks  may 
produce  a  comminuted  fracture,  the 
force  being  transmitted  through  the 

vertebral  column.  Fig.  309  is  a  copy  from  a  specimen  I  placed  in  the 
Wood  Museum  of  Bellevue  Hospital.  The  patient,  a  heavy  man,  a  sail- 
or, fell  through  the  hatchway  to  the  hold  of  the  ship,  a  distance  of  about 
twenty  feet,  striking  on  the  buttocl^s.     Death  occurred  instantly.     The 


Fig.  309. — Comir.inuted  fracture  at  the  btise  of  the 
skull,  from  a  fall  on  the  buttocks,  i  From  a  speci- 
men of  the  author's  in  the  Wood  Museum.) 


FRACTURES.  285 

head  was  not  bruised.  The  cause  of  death  was  a  comminnted  fracture, 
extending  tlirough  the  temporal,  occipital,  and  sphenoid  bones. 

Diagnosis. — The  diagnosis  of  fracture  of  the  vertex  may  be  readily 
determined  when  an  open  wound  exists.  In  many  instances  a  depression 
may  be  determined  by  palpation,  even  when  the  scalp  is  unbroken. 
Symptoms  of  compression  of  the  brain  are  not  reliable  aids  in  the  diag- 
nosis of  fracture  in  the  first  few  days  after  an  injury,  for  the  reason  that 
any  violence  sufficient  to  produce  a  fracture  is  also  likely  to  produce 
symptoms  of  concussion  which  might  easily  be  mistaken  for  compres- 
sion. The  escape  of  brain-substance  or  the  ventricular  fluids  is  of 
course  an  unmistakable  sign.  At  the  base,  one  of  the  most  reliable 
symptoms  of  fracture,  yet  not  always  a  positive  indication  of  this  lesion, 
is  haemorrhage,  or  the  esca];)e  of  a  serous  fluid  from  the  ears.  This  only 
occurs,  however,  when  the  line  of  fracture  passes  through  the  petrous 
portion  of  the  temporal  bone.  Swelling  of  the  vault  of  the  pharynx  is 
not  without  significance  when  any  violence  has  been  suffered  which  leads 
to  the  suspicion  of  fracture  of  the  skull.  If  the  basilar  process  of  the 
occipital  bone  is  involved,  extravasation  will  not  unlikely  be  present  in 
this  region.  Loss  of  vision  or  the  sense  of  smell  indicate  lesion  of  the 
anterior  fossa.  In  many  instances  the  diagnosis  must  rest  wholly  upon 
subjective  symptoms. 

Based  upon  no  objective  symptoms,  the  differentiation  between  con- 
cussion and  comjjression  of  the  brain  is  difficult,  and  often  impossible. 

In  general,  it  may  be  said  that  the  symptoms  of  compression  are  those 
of  paralysis,  usually  unilateral  and  more  profound  than  the  symptoms  of 
concussion. 

In  simple  concussion  the  patient  may  be  aroused  to  partial  conscious- 
ness, the  respiratory  movements  of  the  muscles  of  the  face  will  be  sym- 
metrica], equality  of  the  pupils  is  maintained,  and  vomiting  is  of  frequent 
occurrence.  In  compression,  stupor  is  apt  to  be  prolonged  and  pro- 
found, the  facial  muscles  are  drawn  to  one  side,  and  the  buccinator  of  the 
affected  side  is  apt  to  puff"  out  with  the  expiratory  effort.  There  may  be 
inequality  of  the  pupils,  and  vomiting  is  absent. 

In  the  treatment  of  concussion  of  the  brain  the  first  indication  is  rest. 
The  recumbent  posture,  with  the  head  elevated,  should  be  maintained. 
If  there  is  marked  coldness  of  the  skin,  and  evidence  of  great  prostration 
or  impending  collapse,  warmth  should  be  applied  locally,  and  stimulants 
hypodermically.  Stimulants  miist,  however,  be  given  with  discretion, 
since  the  fever  of  reaction  may  be  increased  by  their  excessive  use. 
After  the  shock  passes  off,  cold  applications  to  the  head  are  essential. 

The  treatment  of  fractures  at  the  base  is  altogether  expectant.  Sur- 
gical interference  is  rarely  if  ever  called  for.  In  fractures  of  the  vault, 
with  depression,  in  adults,  the  trephine  should  be  applied  as  soon  after 
the  injury  as  is  consistent  with  the  patient's  safety.  If  shock  is  ijresent 
without  serious  compression,  it  will  be  wise  to  wait  until  reaction  is  es- 
tablished. When,  however,  dangerous  depression  exists,  immediate  op- 
eration, even  without  an  ansesthetic,  is  demanded.  When  the  symptoms 
of  depression  are  not  prominent,  an  exploratory  incision  is  justifiable  in 


286  A  TEXT-BOOK   ON   SURGERY. 

order  to  determine  with  certainty  whether  there  is  compression  of  the 
brain  or  meninges.  With  antiseptic  precautions  this  operation  adds 
little  to  the  o-ravity  of  the  patient's  position. 

A  comminuted  fracture  in  an  adult  always  demands  the  elevation  and 
removal  of  the  fragments.  A  linear  fracture,  with  depression,  even  if  this 
is  thought  to  be  confined  to  the  outer  plate,  also  demands  the  trephine  as 
far  as  the  diploe,  and,  if  the  depression  involves  the  inner  table,  this 
should  also  be  raised  and  the  fragments  rem^oved.  A  fracture  made  by  a 
narrow  instrument,  or  other  penetrating  substance,  as  a  gunshot  missile, 
etc.,  demands  the  trephine  at  the  point  of  entrance.  In  children,  the  tol- 
eration of  the  brain  to  pressure  is  such  as  to  justify  delay  in  elevation  of 
the  fragments  unless  alarming  symptoms  supervene. 

Localized  paralysis,  coming  on  immediately  after  an  injury  to  the 
skull,  calls  for  trephining  at  once.  It  is  always  better  to  operate  early 
than  to  defer  interference  until  inflammatory  symptoms  are  present. 
The  danger  is  enhanced  by  such  delay.  The  disrepute  which  this  o^Dera- 
tion  has  fallen  into  has  been  chiefly  due  to  too  great  procrastination  in 
surgical  interference. 

Operation. — Besides  the  ordinary  cutting  and  haemostatic  apparatus, 
a  trephine  and  elevator  will  be  found  necessary,  while  a  rongeur  and 
sequestrum-forceps  will  be  of  great  service.  Of  the  various  trephines, 
the  conical  instrument  of  Gait  is  preferable  (Fig.  80). 

The  scalp,  within  two  or  three  inches  of  the  wound,  should  be  shaved 
perfectly  clean,  and  it,  together  with  the  hair,  washed  with  l-to-3.000 
sublimate  solution.  A  rubber  band  or  piece  of  drainage-tube  carried 
around  the  head,  dipping  beneath  the  occiput,  and  passing  above  the 
ears  and  eyebrows,  will  control  all  bleeding  from  the  scalp.  Catgut 
ligatures  may  be  applied  later.  In  cutting  down  to  the  bone,  any  wound 
which  may  exist  should  be  utilized,  and  may  be  enlarged  by  a  crucial 
incision,  if  found  necessary.     The  periosteum  should  not  be  lifted. 

When  the  fracture  is  well  exposed,  if  there  is  great  comminiition,  and 
if  the  fragments  are  not  tightly  impacted,  they  may  be  lifted  by  the 
elevator  without  trephining.  If  this  instrument  is  required,  advance  the 
central  bit  about  one  eighth  of  an  inch  beyond  the  level  of  the  circular 
teeth,  and  fasten  it  firmly  here  by  turning  the  screw  near  the  center  of 
the  shaft.  The  point  of  the  bit  should  be  applied  upon  the  solid  unfract- 
ured  bone,  about  one  fourth  of  an  inch  from  the  fissure,  and  the  greater 
part  of  the  button  lifted  from  the  uninjured  bone.  The  instrument  is 
now  caused  repeatedly  to  rotate  for  a  half  circle  and  back,  and  sufficient 
pressure  is  made  to  carry  the  point  and  teeth  into  the  calvarium.  When 
the  teeth  have  cut  a  circle  about  one  sixteenth  of  an  inch  in  depth  the 
instrument  should  be  removed,  and  the  bit  slipped  up  the  shaft  to  its 
original  position.  As  the  operation  proceeds,  the  trephine  should  be  re- 
moved every  few  turns  and  the  ring  cleaned  out  with  a  tooth-pick.  A 
slight  bleeding  is  apt  to  occur  when  the  diiDloe  is  entered.  As  soon  as 
the  inner  table  is  divided  the  instrument  becomes  locked  and  practically 
immovable.  Wounding  the  dura  mater  is  scarcely  probable  if  the  trephine 
is  held  perpendicular  to  the  plane  of  the  bone  which  is  being  cut.    If  the 


FRACTURES.  287 

button  does  not  come  up  with  tlie  instrnment.  it  slionld  be  lifted  out  with 
the  elevator  or  forceps.  The  elevator  may  now  be  carried  carefully  under 
the  edge  of  the  depressed  bone,  and,  using  the  solid  siuiace  for  a  fulcrum, 
lifted  into  position,  or,  if  com- 
minuted, removed.  It  is  always  .^--^^  ir~^ 
important  to  look  for  any  frag- 
ments, however  small,  which  are 
apt  to  be  broken  off  from  the 
vitreoiis  table  and  driven  be- 
tween the  dura  mater  and  the 
skull.  If  the  dura  be  torn,  the 
bleeding  should  be  arrested  by 
catgut  ligatures,  and  the  wound 
in  this  membrane  closed  by  sut-  ^  / 
ures  of  the  same  material  rFis.       ^  "'^^^.y^               ^                              y 

The  wound  should  be  treat- 
ed under  strict  antisepsis,  and 
should   be    kept    open   with    a 

Ti.T           .              Si     •     -i    e          -J  Fi&.   310. — FmgmentB   removed    bv  the    trephine  and 

Ught     dressing    OI    lOdOIOrmiZed  elevator  in  a  depressed  fracture  caused  hy  a  blow 

onrl  i5nl-.1iTnri(-a  rrmT7Q  with  a  hammer.    The  beveling  at  the  expense  of  the 

ana  liUDlimate  gauze.  vitreous  table  is  well  shown. 

The  trephine  should  not  be 
applied  over  the  track  of  the  longitudinal  or  lateral  sinuses  and  the 
middle  meningeal  artery.      DejDressed  bone  may  be  lifted  from  these 
vessels.     Haemorrhage,  if  it  occur,  may  be  controlled  by  the  ligature  or 
by  compression. 

J^asal  Bones. — One  or  both  nasal  bones  maybe  fractured  and  de- 
pressed, and  in  severe  injuries  the  nasal  processes  of  the  superior  maxilla 
and  the  perpendiciilar  plate  of  the  ethmoid  are  involved. 

Hsemorrhage  from  within  the  nose  is  usually  severe,  and  may  require 
the  tamx^on  of  the  anterior  and  posterior  nares.  The  reposition  of  the 
fragments  should  be  effected  with  gi'eat  care.  A  strong,  blunt,  and  nar- 
row instrument  passed  along  the  septum  nasi  until  it  is  in  contact  with 
the  inner  surface  of  the  fragments,  together  with  lateral  pressure  from 
without  and  at  the  base  of  the  nose,  will  best  reduce  the  displaced  pieces. 
In  order  to  hold  the  fragments  in  position,  the  method  of  ti'eatment  in- 
troduced by  Dr.  Lewis  D.  Mason  will  be  found  preferable.  After  reposi- 
tion, as  above  described,  a  steel  drill  is  passed  dii'ectly  across  the  nose, 
being  entered  through  the  line  of  fracture  or  beneath  it.  Over  the  ends, 
which  project  through  the  integument  on  either  side  of  the  nose,  a  strip 
of  pure  rubber  "is  placed,  across  the  bridge  of  the  nose,  by  puncturing 
either  end  on  the  head  and  point  of  the  needle,  giving  the  rubber  suffi- 
cient tension  to  exert  a  gentle  downward  and  lateral  compression,  but 
not  enough  to  interfere  with  the  circulation  or  to  exert  a  degree  of  press- 
ure on  the  fragments.  The  point  and  head  of  the  needle  may  be  pro- 
tected by  small  pieces  of  cork."*    The  accompanying  ctit  (Fig.  309a) 

*  "  Annals  of  Anatomy  and  Surgery,"  vol.  ii,  pp.  110  and  199. 


288  A  TEXT-BOOK   ON   SURGERY. 

illustrates  tlie  employment  of  tins  procedure.  This  patient  received  a 
kick  which  drove  the  nasal  process  of  the  superior  maxilla  of  the  right 
side  and  the  right  nasal  bone  into  the  cavity  of  the  nose.  The  deformity 
was  marked  and  the  voice  greatly  changed  and  unusually  nasal  in  tone. 
The  bones  could  be  readily  replaced,  but  would  return  to  their  abnormal 

position  as  soon  as  the  instrument 
was  withdrawn.  Under  ether  I  re- 
placed the  fragments,  and,  while 
held  in  proper  position,  I  drove  one 
of  my  steel  fixation-drills  from  side 
to  side,  passing  it  beneath  the  loos- 
ened pieces.  A  light  loop  of  iodo- 
form gauze  was  twisted  across  the 
nose  and  over  the  ends  of  the  drill. 
The  instrument  remained  in  place 
ten  days,  was  removed,  and  a  proper 
cure  attained. 

The  drill  may  be  removed  about 
-y       \  y  •'4    i'^^^S'jh  *^^  sixth  to  the  tenth  day.     When 

\.     ^T^    ^/'^^^  *^^  blow  is  received  on  the  side  of 

. .    \  __-  > .  j^g  nose,  the  fracture  and  depression 

Fia.  309A.-caseofO'Tooie.  ^^y  be  Unilateral.     In  such  cases, 

replacement  effected  after  the  man- 
ner just  described  will  usually  suffice,  since  the  fragments  are  not 
likely  to  be  displaced  when  once  in  position.  When  the  fracture  is 
bilateral,  the  drill  should  be  entered  at  the  level  of  solid  and  unbroken 
bone,  on  one  side,  if  possible.  When  the  bones  are  widely  comminuted 
a  second  drill  may  be  utilized.  In  those  instances  where  the  perj)en- 
dicular  plates  of  the  ethnoid  or  vomer  are  broken,  after  reposition  and 
fixation  with  the  drills,  any  lateral  deviation  of  the  septum  should  be 
corrected.     Plugs  of  gauze  may  be  carried  into  the  nares,  if  necessary. 

At  times,  and  especially  in  children,  when  the  nasal  arch  is  struck 
from  the  front,  the  fracture  occurs  at  the  naso-maxillary  suture,  and  the 
nasal  bones  are  driven  in  without  comminution.  In  this  variety  of  de- 
pression considerable  force  is  needed  to  efl'ect  reduction.  Such  is  the 
rapidity  with  which  repair  and  union  occur  here,  as  in  all  the  bones  of 
the  face,  that,  if  the  effort  at  reduction  is  delayed  for  more  than  twenty- 
four  or  forty-eight  hours  it  will  be  exceedingly  difficult,  if  not  impos- 
sible, to  accomplish. 

Fracture  of  the  malar  bone  occurs  rarely,  and  is  the  result  of  violence 
so  great  that  usually  the  upper  jaw  and  other  bones  are  broken.  Every 
effort  should  be  made  to  restore  the  normal  contour  to  the  face  by  repo- 
sition of  the  fragments,  none  of  which  should  be  removed,  since  the 
vitality  of  the  bones  of  the  face  is  so  great  that  necrosis  after  injury  is 
exceptional. 

AVhen  the  fracture  is  compound,  and  this  is  usually  the  case,  the 
fragments  may  be  lifted  into  place  through  the  wound,  by  means  of  the 
bullet-screw  elevator,  or  other  instruments  ;  or,  as  advised  by  HamiltoUj 


FRACTURES.  289 

the  finger  or  tliiimb  may  be  passed  undemeath  the  lip  to  the  zygomatic 
arch,  which  can  be  utilized  as  a  point  for  pressure.  At  times,  however, 
it  may  be  necessary  to  enter  the  antrum  maxillare  by  trephining  or  drill- 
ing through  the  anterior  wall  of  the  antrum.  The  point  of  entrance 
should  be  immediately  above  the  first  (or  anterior  molar)  tooth,  at  a  dis- 
tance of  from  one  half  to  three  fouiths  of  an  inch  below  the  inferior  mar- 
gin of  the  orbit. 

Fracture  of  the  zygomatic  process,  either  of  the  malar  or  temporal 
bones,  may  occur  singly  or  as  a  complication  of  the  fracture  just  treated. 
If  the  force  which  produces  the  lesion  does  not  wound  the  temporal  or 
maxillary  arteries,  the  treatment  is  simple.  If  the  depression  is  sufficient 
to  cause  defonnity,  cut  down  to  the  arch,  insert  a  hook  elevator,  and  lift 
the  bone  into  place.  It  may  be  necessary  to  limit  mastication  by  the  ap- 
plication of  a  bandage,  as  in  fracture  of  the  lower  jaw. 

The  superior  maxilla  may  alone  be  broken,  although  it  is  usually 
comi:)licated  with  fracture  of  other  bones.  A  blow  received  at  the  roots 
of  the  teeth  may  drive  the  alveolar  and  palatal  arch  downward,  or,  if  the 
direction  of  the  impinging  body  is  from  before  backward  and  upward, 
the  antrum  may  be  opened. 

The  treatment  is  to  cleanse  the  wound  antiseptically  and  replace  all 
pieces  of  bone  as  weU  as  possible. 

The  following  case  Illustrates  in  a  remarkable  degree  the  vitality  and 
reparative  power  in  the  bones  of  the  face :  In  September,  1884,  a  robust 
Irishman,  about  forty  years  of  age,  came  into  my  service  at  Mount  Sinai 
Hospital.  He  had  just  been  kicked  by  an  unshod  horse.  The  crescentic 
wound  extended  from  the  center  of  the  forehead  down  by  the  nasal  pro- 
cess, along  the  facial  groove,  and  out  beyond  and  below  the  malar  bone. 
The  soft  tissues  were  lacerated,  and  the  bones  extensively  comminuted. 
The  wound  was  cleansed  of  paiticles  of  manure,  straw,  and  pieces  of 
hoof.  Strict  antisepsis  was  employed,  thoroughly  cleansing  the  wound 
and  replacing  every  piece  of  bone.  The  torn  edges  were  pared  and  closed 
by  silk  suttires.  Rapid  tinion  ensued,  without  the  exfoliation  of  any 
portion  of  the  bone. 

The  great  desideratum  is  the  prevention  of  a  scar.  Upon  the  face  the 
greatest  care  must  be  taken  to  avoid  deformity.  H  the  soft  tissues  are 
torn  and  contused,  the  edges  of  the  wound  should  be  smoothly  pared  and 
nicely  approximated  by  fine  silk  sutures. 

"\Yhen  the  destruction  of  the  bone  is  so  extensive  that,  even  after  re- 
position of  the  pieces,  the  fragments  will  not  remain  in  place,  it  may  be 
necessary  to  use  the  lower  jaw  as  a  splint,  by  fixation  of  the  two  rows 
of  teeth,  with  the  head  and  chin  figure-of-8  dressing,  as  for  fracture  of 
the  lower  jaw.  The  interposition  between  the  teeth  of  short  strips  of 
gutta-percha,  thoroughly  softened  in  warm  water,  will  firmly  fix  the 
broken  to  the  unbroken  bones,  and  admit  of  the  introduction  of  liqtiid 
food  between  the  upper  and  lower  incisors. 

Fracture  of  the  inferior  maxilla  may  occur  in  rare  instances  through 
the  syrapJiysis  menti,  but  much  more  frequently  external  to  this  and 
near  the  opening  of  the  mental  foramen.     The  majority  of  all  fractures 

19 


290  A  TEXT-BOOK   ON  SURGERY. 

are  of  the  body,  and  within  the  first  inch  and  a  half  leading  backward 
from  the  symphysis. 

Fracture  of  the  angle  or  ramus  is  infrequent,  and  is  usually  the  result 
of  a  blow  upon  the  side  of  the  Jaw.  The  coronoid  process  is  rarely  if 
ever  broken,  except  by  penetrating  bodies.  The  condyle  may  be  broken 
through  its  neck  by  a  fall  or  blow  on  the  chin,  or  by  force  applied  later- 
ally at  or  near  the  angle. 

Diagnosis. — Among  the  symptoms  of  this  lesion  are  pain  at  the  point 
of  fracture  and  loss  of  function.  If  the  break  is  complete,  the  diagnosis 
is  made  evident  in  the  displacement  which  usually  occurs,  and  by  the 
presence  of  crepitus.  This  bone  may,  however,  be  broken  without  dis- 
placement, and  where  crepitus  is  not  present.  Under  such  conditions, 
while  a  diagnosis  may  not  be  positive  until  the  swelling  which  indicates 
the  formation  of  callus  ensues,  the  jaw  should  be  kept  at  rest  by  one  of 
the  methods  to  be  described.  When  the  fracture  occurs  at  or  posterior 
to  the  mental  foramen,  the  temporary  loss  of  function  of  the  inferior 
dental  nerve,  which  is  not  infrequent,  jjoints  almost  unerringly  to  a 
recognition  of  the  character  of  the  lesion.  When  the  neck  of  the  condyle 
is  broken,  the  chief  symptom  is  pain  in  this  region,  with  partial  or  com- 
plete loss  of  function.  Crepitus  is  with  difficulty  elicited  by  the  surgeon, 
although  it  may  be  evident  to  the  patient. 

Treatment  and  Prognosis. — Immediate  reposition  of  the  broken  and 
displaced  surfaces,  and  as  perfect  a  degree  of  rest  as  possible,  are  the 
first  and  chief  indications  for  treatment.  When  the  presence  of  a  par- 
tially displaced  tooth  ofl'ers  an  obstacle  to  close  adaptation  it  should  be 
removed.  AVhen  reduction  is  effected,  one  among  the  following  methods 
may  be  employed : 

A  simple  and  ready  method,  which  may  be  used  until  a  more  secure 
apparatus  is  constructed,  is  found  in  the  four-tailed  bandage  (Fig.  32). 
The  fragments  being  carefully  adjusted,  the  bandage  is  applied  as  already 
given  on  page  20.  The  figure-of-8  chin  and  head  bandage  (Fig.  24)  is 
also  an  excellent  emergency  dressing  for  fracture  of  the  lower  jaw.  If 
this  is  intended  to  be  used  permanently,  a  leather  or  gutta-percha  cup 
should  be  constructed,  to  fit  over  the  chin  and  well  along  the  body  of  the 
jaw.  The  material  should  be  cut  from  three  to  three  and  a  half  inches 
wide  and  about  six  to  seven  inches  in  length,  and  split  from  each  end  in 
its  long  axis  to  within  three  fourths  of  an  inch  of  the  center.  One  strip 
should  be  about  half  an  inch  narrower  than  the  other.  If  gutta-percha 
is  used,  this  should  be  dipped  in  warm  water  for  a  minute  or  two,  until 
it  becomes  softened.  It  is  then  laid  across  the  chin,  the  upper  and  nar- 
row ends  are  turned  back  over  and  parallel  with  the  body  of  the  jaw, 
while  the  lower  ends  are  turned  upward  and  made  to  cross  outside  the 
horizontal  ends.  The  bandage  is  applied  over  this  cup,  which  soon 
hardens  into  an  unyielding  dressing.  Leather  may  be  prepared  in  the 
same  way,  but  requires  to  be  soaked  longer  than  the  rubber.  Inter-dental 
splints,  made  of  gutta-percka  strips,  cut  about  one  inch  and  a  half  in 
length,  from  one  fourth  to  one  half  an  inch  in  width,  and  about  one 
fourth  of  an  inch  in  thickness,  are  sometimes  employed  to  fix  the  molar 


FRACTTJKES. 


291 


teetli  immovably,  and  at  the  same  time  to  separate  tlie  anterior  teeth, 
enongh  to  allow  of  the  introduction  of  liquid  food.  These  strips  should 
also  be  softened,  and,  when  placed  between  the  teeth,  the  crowns  of  the 
molars  are  pressed  into  the  rubber  by  the  di'essing.  "When  the  fracture 
is  through  the  molar  region,  the  strip  on  the  broken  side  is  placed  on 
either  side  of  the  fracture. 

The  most  suitable  apparatus  is  that  of  Prof.  Hamilton,  seen  in  Fig. 
311.  It  consists  of  a  chin-and-head  strap,  made  of  strong,  soft  leather. 
This  piece,  where  it  passes  under  the  chin, 
is  shaped  so  that  while  it  may  not  cause 
uncomfortable  pressure  at  the  base  of  the 
tongue,  it  is  wide  enough,  as  it  passes  up 
on  to  the  side  of  the  face,  to  include  the 
angle  of  the  jaw  in  its  support.  From  this 
point  it  is  gradually  narrowed,  until  at  the 
temple  it  is  an  inch  in  width,  and  the  same 
where  it  is  buckled  at  the  fronto-parietai 
suture.  A  piece  of  cloth,  fashioned  so  as 
to  fit  like  a  cup  over  the  chin,  is  sewed  on 
to  this.  A  second  strip  is  buckled  around 
the  head,  across  the  forehead  and  beneath 
the  occiput,  and  fi'om  this  point  an  antero- 
posterior strap  passes  forward  to  the  max- 
illary piece,  to  which  it  is  attached  at  the 
fronto-parietai  Junction.  By  shortening  or 
elongating  this  strap  the  du-ection  of  the  pressure  on  the  Jaw  can  be 
changed,  while  it  prevents  the  maxillary  strip  from  puEing  forward.  A 
piece  of  soft  lint  or  cotton  should  be  placed  under  each  buckle.  If,  after 
the  apparatus  is  applied,  the  teeth  fit  so  closely  together  that  it  is  impos- 
sible to  introduce  liquid  nourishment,  inter-dental  splints  of  gutta-percha 
should  be  employed.  In  some  instances  it  will  be  necessary  to  unite  the 
fragments  by  silver-wire  sutures.  The  sutures  usually  require  to  be  re- 
moved after  union  is  secured. 

A  patient  with  a  fi-actured  Jaw  should  not  be  allowed  to  talk,  and, 
when  in  bed,  should  be  required  to  rest  in  the  dorsal  decubitus,  so  as  not 
to  press  laterally  upon  the  injured  bone. 

The  prognosis  is  usually  favorable.  Fixation  by  ossification  occurs 
in  from  two  to  five  weeks.  In  some  cases  later,  while  in  a  small  number, 
in  which  proper  treatment  has  been  delayed,  or  the  character  of  the  in- 
Jury  severe,  or  the  condition  of  repair  in  the  patient  unfavorable,  iinion 
is  delayed  or  fails  utterly.  In  instances  of  delayed  union  fixation  should 
be  faithfully  tried.  If  this  fails,  and  the  function  of  the  Jaw  is  seriously 
impaired,  the  point  of  fracture  should  be  ex[30sed  by  incision,  the  broken 
edges  scraped,  one  or  two  holes  drilled  through  each  fragment,  one  fourth 
of  an  inch  from  the  edges,  and  fixation  secured  by  means  of  silver  wkes. 

Fracture  of  the  cartilages  of  the  larynx  is  of  rare  occurrence.  Sim- 
ple fracture  heals  -nithout  retentive  apparatus,  quiet  being  the  chief  indi- 
cation.    The  prognosis  is  grave  in  proportion  to  the  danger  of  asphyxia 


i'lG.  311.— (After  Hamilton.; 


292 


A  TEXT-BOOK  ON  SURGERY. 


from  inflammatory  swelling  or  emphysema.  When  the  force  has  been 
great,  and  the  comminution  extensive,  death  may  occur  fi-om  shock  or 
other  complication  before  asphyxia  from  occlusion  of  the  trachea  super- 
venes. When  this  last  danger  is  threatened,  tracheotomy  should  be  per- 
formed early. 

When  the  os  hyoides  is  broken,  the  fragment,  if  displaced  or  driven 
through  the  soft  tissues,  may  be  brought  into  position  by  introducing 
one  finger  into  the  mouth  and  pressing  with  the  other  hand  from  with- 
out. It  is  scarcely  possible  to  retain  the  ends  in  apposition,  and  fibrous 
union  is  apt  to  occur.  The  accident  is  rare,  is  not  dangerous,  and  the 
prognosis  consequently  favorable. 

Clamcle. — The  clavicle  is,  next  to  the  radius,  more  frequently  the  seat 
of  fracture  than  any  other  bone.  In  children  the  fracture  is  rarely  com- 
plete, and  consequently  overlapping  is  not  met  with,  as  is  the  rule  in 
adults.  The  break  occurs,  in  a  large  majority  of  instances,  in  the  middle 
third,  i.  e.,  in  that  portion  of  the  bone  between  the  attachments  of  the 
trapezius  and  sterno-mastoid  muscles.  This  fracture  may  be  caused  by 
direct  violence,  or  by  indirect  force,  as  a  fall  upon  the  shoulder  or  the 
extended  arm. 

The  character  of  the  displacement  is  shown  in  Fig.  312.  The  inner 
fragment  is  held  in  position  by  the  mastoideus  muscle,  and  is  prevented 
from  being  carried  iipward  by  the  costo-clavicular  ligament.     The  weight 

of  the  arm  and  shoulder  drags  the  outer 
fragment  downward,  while  the  contractions 
of  the  pectoralis  major,  latissimus  dorsi, 
and  subclavius  muscles  carry  it  toward 
the  middle  line  of  the  body,  beneath  the 
inner  fragment.  In  rare  instances  the  dis- 
placement is  the  reverse. 

The  diagnosis  rests  upon  loss  of  func- 
tion, pain  at  the  seat  of  lesion,  possibly 
crepitus,  loss  of  symmetry,  shortening, 
and  recognition  of  displacement  by  pal- 
pation. 

The  prognosis  is  good  as  to  restoration 
of  function,  although,  in  complete  fract- 
ure, overlapping  and  a  certain  amount  of 
permanent  deformity  and  shortening  are 
almost  inevitable. 

Treatment. — In  complete  fracture  over- 
lapping of  the  fragments  may  be  correct- 
ed, and  the  ends  brought  into  apposition, 
by  first  carrying  the  arm  and  shoulder 
the  shoulder.  This  is  the  principle  in- 
volved in  Prof.  Sayre's  excellent  method  of  treating  this  lesion,  which  is 
as  foUows  :  Cut  two  strips  of  strong  adhesive  plaster  (moleskin  is  prefer- 
able) about  three  inches  wide  and  several  feet  in  length.  Just  above  the 
elbow  of  the  arm  on  the  injured  side,  one  strip,  with  the  adhesive  surface 


Fig.  312.— (From  Gray.) 


backward,  and  then  elevatino 


FRACTURES. 


293 


nearest  tlie  body,  is  passed  around  the  arm  and  secured  with  a  safety-pin, 
so  that  it  will  not  constrict  the  member  (Fig.  313).     The  hand  is  now  laid 


Fia.  313.— The  first  strip. 


Fio.  314. — Sayre's  dressing  for  fractured  clavicle. 
Front  view. 


over  the  middle  of  the  sternum,  the  shoulder  elevated,  and  the  elbow 
carried  well  backward  by  an  assistant,  while  the  operator  carries  the 
plaster  directly  around  the  body  by  the  back,  fastening  it  snugly  to  the 
integument.  The  second  strip  is  split  near  its  middle  for  about  three 
inches,  for  the  accommodation  of  the 
elbow,  and  is  applied  along  the  fore- 
arm and  over  the  shoulder  of  the 
sound  side,  and  obliquely  around  the 
back  to  the  same  laoint  (Figs.  814, 
815).  A  wad  of  absorbent  cotton 
should  be  placed  in  the  axiUa  of  the 
affected  side,  and  between  the  hand 
and  the  sternum.  The  plasters  should 
be  stitched  or  fastened  securely  with 
safety-pins. 

A  convenient  and  effective  ready- 
method  is  that  of  Prof.  Moore,  of 
Rochester.  A  strip  of  sheeting,  eight 
inches  in  width  and  three  yards  long, 
is  held  near  its  center  across  the  palm 
of  the  operator,  who,  for  the  left 
clavicle,  grasps  the  elbow  of  this  side 
from  behind.  That  end  of  the  strip  which  is  next  the  patient's  body  is 
passed  between  the  arm  and  chest,  then  up  in  front  of  and  over  the  clav- 
icle of  the  injured  side,  obliquely  across  the  back,  under  the  opposite 
axilla,  thence  across  the  right  clavicle,  and  over  this  to  the  back. 

The  opposite  end  is  passed  to  the  front  of  the  arm  at  the  elbow,  be- 
tween the  first  strip  and  the  arm,  and  is  then  carried  around  the  back. 


Flo.  315. — Sayre's  second  strip  for  fractured 
clavicle.    Back  view. 


294 


A  TEXT-BOOK   ON   SURGERY. 


An  assistant  now  carries  tlie  elbow  backward  and  upward,  and,  while 
held  in  this  position,  the  bandage  is  tied,  sewed,  or  pinned.  A  sling  to 
support  the  foreai-m  is  added.  This  is  practically  a  figure-of-8  band- 
age around  the  elbow  of  the  broken  side  and  the  shoulder  of  the  sound 


Fig.  316.— Moore's  method. 


Fig.  317. — Moore's  method. 


side.  The  hand  is  carried  across  the  chest,  slightly  elevated,  and  is 
held  in  a  sling.  Safety-pins  are  inserted  at  the  points  of  crossing  (Figs. 
316,  317). 

In  incomplete  fracture,  and  in  children,  especially  during  the  summer 
months,  when  the  plaster  tends  to  produce  irritation  of  the  skin,  Vel- 
peau's  method  is  preferable.     (See  page  327.) 

Any  form  of  apparatus  should  be  worn  at  least  four  weeks. 

The  scapula  is  almost  always  broken  by  direct  violence.  It  is 
thought  to  have  been  fractured  in  a  few  instances  by  muscular  action 
alone. 

Acromion  Process. — The  acromion  process  is  usually  broken  by  a 
fall  on  the  shoulder  or  a  blow  received  from  above.  The  fracture  may 
occur  anterior  to,  through,  or  behind  the  acromio-clavicular  articulation. 
The  diagnosis  is  evident  from  crepitus,  preternatural  mobility,  and  de- 
pression of  the  outer  end  of  the  clavicle.  The  treatment  is  to  bend  the 
forearm  at  a  right  angle  to  the  arm,  and  throw  a  roller  under  the  forearm, 
at  the  elbow,  and  over  the  clavicle  and  shoulder  of  the  affected  side,  fix- 
ing the  head  of  the  humerus  in  the  upper  part  of  the  shoulder-Joint  and 
lifting  the  acromion  into  its  place. 

Coracoid  Process. — When  this  process  is  broken  the  tendency  to  dis- 
placement is  downward,  owing  to  the  action  of  the  pectoralis  minor, 
coraco-brachialis,  and  short  head  of  the  biceps.  Unless  the  fracture  is 
anterior  to  the  attachments  of  the  coraco-clavicular  ligaments,  or  unless 
these  have  been  detached,  the  displacement  can  only  be  limited. 


FRACTURES.  295 

Treatment. — Place  the  hand  of  the  injured  side  on  the  opposite  shoul- 
dei',  and  apply  Velpeau's  bandage  as  for  fracture  of  the  clavicle.  The 
prognosis  is  good,  although  fibrous  union  is  the  rule. 

Fracture  of  the  glenoid  process — that  is,  through  that  portion  of  the 
scapula  between  the  glenoid  fossa  and  the  anterior  portion  of  the  base  of 
the  coracoid  process — has  not  yet  been  noted.  Several  instances  are  re- 
corded, however,  of  fracture  which,  while  anterior  to  the  base  of  the 
acromion,  included  the  base  of  the  coracoid  process. 

Treatment. — Flex  the  forearm  at  right  angles  to  the  arm,  and  carry  it 
across  the  chest,  leaving  the  humerus  jDaraUel  with  the  axis  of  the  body. 
Lift  the  hiimerus  directly  upward  against  the  coraco-acromial  ligament, 
place  a  pad  in  the  axilla,  and  carry  a  roller  around  and  under  the  fore- 
arm, at  the  elbow,  and  over  the  shoulder  of  the  same  side.  Every  other 
turn  should  be  carried  horizontally  around  the  body.  By  this  means  the 
head  of  the  humerus  keeps  the  fragment  in  position. 

Fracture  of  the  siaine  of  the  scapula  is  rare,  but  below  this  it  is  of 
more  frequent  occurrence.  Velpeau's  bandage,  or  any  method  which 
will  give  the  minimum  of  discomfort  and  the  greatest  degree  of  rest,  will 
be  most  successful. 

Humerus. — Fracture  of  the  humerus  occurs  most  frequently  in  its 
lower  third,  while  the  proportion  of  fractures  in  the  middle  and  upper 
thirds  is  about  equal. 

In  the  upi3er  third  this  bone  may  be  broken  through  the  anatomical 
neck  ;  just  below  this  line,  through  the  tuberosities  ;  immediately  below 
the  tuberosities  (the  surgical  neck) ;  or  through  the  shaft.  It  may  also  be 
fractured  longitudinally,  with  separation  of  the  tubei'osities. 

Fracture  of  the  anatomical  necTc,  or  intra-capsular  fracture,  is  rare. 
It  is  caused  by  a  blow  or  fall  directly  on  the  shoulder. 

Diagnosis. — There  may  be  crepitus.  If  the  shoulder  is  fixed  and  the 
humerus  grasped  below  and  up  to  the  tuberosities,  and  crepitus  is  felt  by 
moving  the  head  against  the  glenoid  cavity,  the  character  of  the  injury 
is  evident.  If  impaction  into  the  shaft  has  occurred,  crepitus  will  be 
absent,  but  shortening  will  be  ascertained  by  careful  measurement. 

Bony  union  after  intra-capsular  fracture  is  rare,  unless  impaction  has 
occurred.  Osteo-arthritis  may  result,  rendering  exsection  of  the  joint 
necessary. 

Fracture  through  the  tuberosities  occurs  also  from  direct  violence. 
The  symptoms  closely  resemble  those  of  the  variety  just  described.  The 
prognosis  is  more  favorable,  since  bony  union  is  the  rule.  Prognosis  as 
to  freedom  of  motion  should  be  guarded,  since  exostosis  may  result  to 
such  an  extent  as  to  interfere  with  the  usefulness  of  the  arm. 

Fracture  through  the  surgical  neclc  is  of  far  more  frequent  occurrence 
than  the  intra-  or  extra-capsular  fractures  at  the  anatomical  neck.  It 
may  result  from  direct  violence,  although  not  infrequently  a  fall  upon 
the  hand  or  elbow  will  produce  it.  The  bases  of  the  tuberosities  are 
rarely  involved  in  fracture  of  the  neck  in  adults — except  in  the  young, 
when  separation  at  the  epiphysis  may  occur.  In  the  middle-aged  and 
old  the  point  of  fracture  is  usually  about  one  inch  below  the  tuberosities. 


296 


A  TEXT-BOOK   ON   SUKGERY. 


Fio.  318. — Showing  the  mechan- 
ism of  displacement  in  fract- 
ure of  the  surgical  neck  of 
the  humerus.    (After  Gray.) 


Displacement  may  occur  in  any  direction,  altliongli  as  a  rule  it  is  not 
extreme.  The  tendency  of  the  lower  fragment  is  to  be  drawn  upward  by 
the  deltoid  and  triceps,  inward  by  the  pectoralis 
major  and  latissimus  dorsi,  and  upward  and  in- 
ward by  the  short  head  of  the  biceps  and  the 
coraco-brachialis  (Fig.  318). 

Longitudinal  Fracture. — This  form  of  fract- 
ure, though  rare,  occurs  from  direct  injury.  The 
split  xasually  runs  through  the  head  of  the  hu- 
merus and  along  the  bicipital  groove,  resulting 
in  a  separation  of  the  greater  tuberosity  from  the 
shaft.  The  bone  will  be  found  to  be  flattened 
and  wider  than  normal,  wliile  a  deep  groove 
marks  the  line  of  cleavage.  The  prognosis  is 
unfavorable  as  to  restoration  of  function. 

Differential  Diagnosis. — In  dislocation  of 
the  shoulder-joint  there  is  always  abnormal  im- 
mobility ;  the  muscles  of  the  shoulder  and  arm 
are  rigid  ;  a  measurement  over  the  acromion  and 
around  through  the  axilla  will  be  at  least  one 
inch  greater  than  on  the  non- dislocated  side  ;  the  head  of  the  bone  will  be 
felt  out  of  its  normal  position ;  if  the  hand  of  the  affected  side  is  laid  upon 
the  opposite  shoulder,  the  elbow  can  not  be  made  to  touch  the  chest-wall. 
In  fracture  without  impaction,  crepitus  and  shortening  ;  more  or  less 
pain  on  motion ;  mobility  free ;  the  circumference  not  increased ;  the 
head  of  the  bone  in  position  ;  with  the  hand  of  the  affected  side  upon 
the  opposite  shoulder  the  elbow  di'ops  to  the  chest.  With  impaction,  all 
of  these  symptoms  except  crepitus. 

Treatment. — Reduction  of  displacement  is  usually  effected  by  exten- 
sion from  the  flexed  forearm,  the  shoulder  being  fixed  by  traction  in  the 
opposite  arm,  or  by  a  sheet  earned  around  the  body,  just  under  the 
axilla.  In  the  first  manoeuvre  it  is  usually  best  to  hold  the  arm  at  right 
angles  to  the  body,  and,  continuing  tlie  extension,  to  bring  it  down  par- 
allel with  the  chest,  in  which  position  it  is  to  be  fixed.  To  this  is  added 
direct  manipulation  of  the  fragments.  The  choice  of  dressings  may  be 
made  between  plaster  of  Paris  and  a  cup-shaped  splint  of  gutta-percha, 
sole-leather,  or  book-binder's  board.  Properly  adjusted,  either  of  these 
materials  will  suflSce.  The  gypsum  dressing  has  the  advantage  of  more 
certain  and  permanent  fixation  of  the  parts.  It  is,,  however,  not  so  com- 
fortable as  the  shoulder-cap  splint. 

It  should  not  be  forgotten  that  there  is  an  element  of  danger  in  ap- 
plying a  fixed  dressing  (gypsum,  glass,  or  starch)  to  a  recent  fracture. 
Should  swelling  occur,  constriction  and  gangrene  may  ensue.  It  is 
always  safer  to  wait  until  swelling  has  subsided,  using  the  cup-shaped 
shoulder-splint  temporarily.  If  deemed  necessary  to  apply  the  gypsum 
dressing  at  once,  directions  should  be  given  to  open  it  enough  to  relieve 
tension  whenever  the  pressure  is  painful  or  constriction  is  evident. 

If  a  shoulder-cap  is  to  be  applied,  a  pattern  is  first  made  by  cutting 


FRACTUEES. 


297 


a  piece  of  paper  to  fit  over  the  shoulder  and  down  the  arm.  It  should 
be  large  enough  to  spread  over  a  j)art  of  the  scapular  and  pectoral  region, 
and  to  embrace  two  thirds  of  the  circumference  of  the  ann.  The  paste- 
board, gutta-percha,  or  leather  is  cut  to  correspond  to  this,  and  is  im- 
mersed in  hot  water  until  it  is  soft  and  pliable,  when  it  is  lined  with  a 
thin  layer  of  absorbent  cotton  and  molded  over  the  arm  and  shoulder, 
where  it  is  secured  by  a  roller,  applied  as  above.  The  inner  side  of  the 
arm  is  protected  by  cotton  or  cloth.  The  forearm  and  hand  should  be 
bandaged,  and  held  in  front  of  the  ensiform  cartilage  by  means  of  a  sling. 
If  the  dressing  becomes  loose,  an  additional  roller  should  be  applied. 
Any  dressing  for  this  fracture  should  be  worn  continuously  for  at  least 
four  weeks.  In  order  to  prevent  contraction  of  the  biceps,  it  will  be  ad- 
visable to  fully  extend  the  forearm  every  two  or  three  days. 

Fractures  of  the  shaft  of  the  humerus,  although  chiefly  caused  by  di- 
rect violence,  are  not  infrequently  the  result  of  a  fall  on  the  hand  or  elbow, 
and  may,  in  rare  instances,  be  caused  by  muscular  action  alone.  The  dis- 
placement, which  is  usually  not  marked,  will  in  great  part  be  determined 
by  the  direction  of  the  line  of  fracture.  If  the  break  is  above  the  inser- 
tion of  the  deltoid,  while  the  lower  fragment  is  drawn  upward  by  the  del- 
toid and  the  long  muscles  extending  from  the  scapula  to  the  elbow,  the 
upper  fragment  is  apt  to  be  drawn  toward  the  thorax  by  the  pectoralis 
major  and  minor  and  latissinras  dorsi  muscles  (Fig.  318).  If  the  break 
is  below  the  deltoid  tubercle,  the  dis- 
placement and  overlapping  will,  in  gen- 
eral, foUow  the  obliquity  of  the  fract- 
ure. The  lower  fragment  is  apt  to  be 
drawn  behind  the  upper  longer  piece. 

The  treatment  is  practically  the  same 
as  that  just  given.  If  the  cup-shaped 
splint  is  used  it  should  be  made  long- 
er, and  an  extra  short,  narrow,  internal 
splint  may  be  added  (Fig.  319).  The 
plaster-of-Paris  dressing  is  very  satis- 
factory in  this  region  of  the  arm. 

Fracture  at  the  condyloid  extremity 
of  the  humerus  may  be  divided  into  : 
1,  transverse  fracture  above  the  con- 
dyles, caused  by  violence  applied  to 
the  elbow  ;  2,  epiphyseal  separation  (on 
a  plane  lower  than  the  above) ;  3,  trans- 
verse fracture,  with  a  longitudinal  split 
into  the  joint  (inter-condyloid)  ;  4,  fract- 
ure of  the  external  condyle ;  5,  of  the  in- 
ternal condyle ;  6,  of  the  external  epicondyle  ;  7,  the  internal  epicondyle. 

In  transverse  fracture  above  the  condyles  the  obliquity  is  usually 
from  behind  forward  and  downward  (Fig.  320),  the  inferior  short  frag- 
ment being  carried  up  behind  the  longer.  When  the  lower  fragment  is 
split  into  the  joint,  the  displacement  is  the  same. 


Fig.  319.- — Apparatus  for  fracture  of  the  hu- 
merus at  any  point  above  the  condyles. 
I^After  Hamilton.) 


298 


A  TEXT-BOOK  ON   SURGERY. 


Fig.  320. — Showing  mechanism  of  dis- 
placement in  fracture  above  the 
condyles.     (After  Gray.) 


In  epiphyseal  separation  the  displacement  is  not  great,  unless  the 
capsule  is  badly  torn,  as  a  result  of  extreme  violence. 

The  treatment  of  these  thi-ee  forms  of 
fracture  is  the  same.  Reduction  by  exten- 
sion and  the  long  L-shaped  cup-splint  of 
Hamilton  should  be  preferred  (Fig.  319). 
This  splint  is  made  of  gutta-percha  (leather 
or  good  card-board  will  suffice  if  the  rubber 
can  not  be  obtained).  It  should  go  from  the 
shoulder  to  the  wrist,  and  the  measurements 
should  be  taken  on  the  unbroken  arm.  The 
apparatus  should  be  padded  with  a  layer  of 
absorbent  cotton.  Instead  of  holding  the 
forearm  at  a  right  angle  to  the  arm,  as  repre- 
sented in  the  cut,  it  is  best  to  carry  it  about 
half  way  between  this  position  and  full  ex- 
tension, in  order  to  carry  the  olecranon  pro- 
cess into  the  fossa,  which,  if  allowed  to  fill 
with  callus,  will  prevent  full  extension  of  the 
forearm.  The  prognosis  is  more  favorable  in 
the  first  variety,  since  the  joint  may  not  be 
involved  in  the  injury.  Destruction  of  the  joint,  requiring  excision,  may 
occur  in  epiphyseal  separation.  When  the  fracture  is  comminuted,  and 
into  the  joint,  anchylosis,  more  or  less  complete,  may  result. 

In  all  fractures  about  the  elbow  it  is  important  to  remove  the  splints 
at  the  end  of  the  third  week,  steady  the  fragments  above  and  below  the 
line  of  fracture  as  well  as  possible,  and  make  limited  motion  at  the  elbow- 
joint.  The  splints  are  again  adjusted,  and  at  the  end  of  another  week 
this  manoeuvre  is  repeated,  with  an  increased  degree  of  motion.  After 
this,  every  two  or  three  days,  until  the  greatest  possible  freedom  of  move- 
ment is  secured.  An  anaesthetic  is  advisable,  to  insure  thoroughness. 
My  preference  is  for  nitrous-oxide  gas,  the  effects  of  which  are  only 
momentary. 

The  internal  condyle  is  broken  much  more  frequently  than  tbe  exter- 
nal. It  is  more  prominent,  and,  in  the  act  of  falling  backward,  the  arms 
are  thrown  out  from  the  body  in  such  a  manner  that  the  inner  condyle 
first  receives  the  force  of  the  fall.  The  fracture  may  be  confined  to  the 
tip  (extra-capsular),  or  it  may  include  a  portion  of  the  internal  epicon- 
dyle,  and  lead  into  the  joint  through  the  trochlear  surface. 

Fracture  of  the  external  condyle  is  of  rare  occurrence.  The  line  of 
cleavage  usually  commences  about  the  middle  of  the  external  condyloid 
ridge,  and  runs  obliquely  to  the  articular  surface,  in  the  groove  between 
the  radial  eminence  and  the  trochlear  surface,  or  through  the  center  of 
this  surface.  The  diagnosis  is  determined  by  the  crepitus,  degree  of 
mobility  of  the  fragment,  and  by  the  partial  loss  of  function  of  the  ex- 
tensor or  flexor  muscles  (as  the  outer  or  internal  condyle  is  afl'ected). 

Treatment. — In  fracture  of  the  inner  condyle,  whether  complete  or 
incomplete,  flex  the  forearm  on  the  arm  to  an  angle  slightly  less  than  45°, 


FRACTURES. 


299 


and  pronate  the  forearm  until  the  back  of  the  hand  is  uppermost.  This 
position  most  fully  relaxes  the  flexors  and  the  pronator  radii  teres.  Use 
the  same  splint  as  just  described.  Place  a  compress  of  cotton  or  lint  in 
front  of  the  condyle,  in  order  to  increase  the  pressure  backward. 

For  the  external  condyle,  bend  the  forearm  as  before,  and  place  the 
hand  palm  upward.  In  all  these  lesions  plaster-of-Paris  or  liquid-glass 
dressings  may  be  used,  although  a  well-made  gutta-percha,  shellac, 
leather,  or  pasteboard  shoulder,  arm,  and  forearm  splint  is  preferable. 

Separation  of  the  epicondyles  is  of  rare  occurrence,  and  demands  no 
especial  mention.  The  indications  for  treatment  are  similar,  and  the 
IDrognosis  more  favorable  than  for  fracture  of  the  condyles. 

Forearm —  Ulna. — Fracture  of  the  olecranon  process  usually  occurs 
as  a  result  of  a  fall  on  the  elbow, 
when  the  forearm  is  in  strong  flex- 
ion. It  is  occasionally  caused  by 
contraction  of  the  triceps.  The  line 
of  fracture  is  most  frequently  at  the 
epiphyseal  junction.  The  displace- 
ment is  upward,  in  the  line  of  the 
triceps  (Fig.  321). 

The  diagnosis  may  be  determined 
by  loss  of  function,  crepitus,  which 
may  be  obtained  when  the  forearm 
is  fully  extended,  or  by  appreciation 
of  the  separation  of  the  two  frag- 
ments. 

Treatment. — Extend  the  forearm 
to  the  fullest  degree  consistent  with 
comfort.  Make  a  soft-board  splint, 
two  or  three  inches  wide,  and  long 
enough  to  extend  from  within  two 
inches  of  the  carpus  to  the  same  dis- 
tance from  the  axilla.     Cut  a  deep 

notch  on  either  side,  three  inches  below  the  level  of  the  line  of  fracture. 
Pad  the  splint  with  batting,  making  it  twice  as  thick  in  the  bend  of  the 

elbow  as  elsewhere, 
and  wrap  it  with  a 
roller.  Lay  the  splint 
on  the  anterior  sur- 
face of  the  arm  and 
forearm,  and  secure  it 
near  the  ends  by  sev- 
eral turns  of  the  roll- 
er. ISText,  take  a  flan- 
nel bandage  (on  ac- 
count of  its  elasticity),  and,  commencing  below,  cover  the  forearm  and 
splint  by  circular  turns  until  the  notch  is  reached,  at  which  moment  the 
roUer  is  carried  well  above  the  upper  fragment,  around  the  posterior 


Fig.  321 . — Displacement  of  the  upper  fragment  m 
fracture  ot  the  olecranon.     (After  Gray.) 


322. — Hamilton's  olecranon  splint.     (After 
Hamilton.) 


Fig.  323. — Hamilton's  dressing  for  fracture  of  the 
olecranon.     (After  Hamilton.) 


300 


A  TEXT-BOOK  ON   SURGERY. 


aspect  of  the  arm,  and  down  again,  to  be  secured  in  the  notch  on  the 
opposite  side  of  the  splint.  This  oblique  turn  is  repeated  until  the  frag- 
ments are  in  apposition,  when  the  whole  is  secured  by  as  many  circular 
turns  as  are  needed  (Fig.  323).  Within  a  week  the  fracture  should  be 
inspected,  by  removing  a  portion  of  the  dressing,  and  additional  turns 
applied  if  any  separation  has  occurred.  After  four  or  five  weeks  the 
splint  should  be  removed,  and  careful  passive  motion  made,  while  the 
fragments  are  supported  by  the  operator.  The  union  is  apt  to  be  liga- 
mentous. 

Fracture  of  the  coronoid  process  is  exceedingly  rare.  The  diagnosis 
is  difficult — often  impossible.  If  the  lesion  is  strongly  suspected,  secure 
quiet  by  apj)lying  a  splint  in  extreme  flexion. 

Fracture  of  the  ulna,  in  its  shaft,  occurs  in  the  effort  to  ward  off  a 
blow,  or  as  a  result  of  a  fall  dii'ectly  upon  the  bone. 

The  diagnosis  is  usually  not  difficult,  even  when  displacement  is  slight. 
In  suspected  fracture  of  one  of  the  bones  of  the  forearm,  if  compression 
be  made  by  grasping  both  bones  at  a  point  remote  from  the  suspected 
break,  and  pain  or  abnormal  mobility  be  caused  at  that  point,  the  diag- 
nosis of  fracture  is  fairly  clear.  If  crepitus  is  obtained,  all  doubt  is  dissi- 
pated. 

Displacement  of  the  upper  fragment  is  always  slight.  The  lower  may 
be  drawn  toward  the  radius  by  the  pronator  quadratus.  The  obliquity 
of  the  cleavage,  and  the  direction  of  the  force  which  produced  the  lesion, 
will  almost  always  determine  the  disi^lacement. 

Radius. — Fracture  of  the  radius  above  the  bicipital  tuberosity  is  one 
of  the  rarest  forms  of  injury,  and,  when  present,  is  with  great  difficulty 
recognized.  The  cause  is  direct  violence.  Displacement  of  the  upper 
fragment  will  be  slight,  unless  the  fracture  is  comj)licated  with  a  disloca- 
tion at  the  radio-humeral  joint.  The  action  of  the  biceps  will  tend  to 
draw  the  lower  fragment  forward.  The  best  position  for  treatment  is  to 
flex  the  forearm  on  the  arm,  with  the  palm  turned  upward,  and  to  apply 
an  anterior  splint,  wider  than  the  arm,  and  provided  with  an  interosseous 

pad.  If  the  displacement  forward 
is  extreme,  a  compress  may  be  em- 
ployed. 

Fracture  of  the  radius  between 
the  bicipital  tuberosity  and  the  in- 
sertion of  the  pronator  radii  teres 
is  also  usually  from  a  direct  blow, 
although  it  may  result  from  a  fall 
on  the  hand,  or  from  muscular  ac- 
tion.*   While  the  obliquity  of  the 
line  of  fracture  will  in  great  part 
determine  the  displacement,  the  tendency  is  for  the  lower  fragment  to 
be  carried   toward  the  ulna  by  the  conjoined   action  of  the  pronator 
quadratus  and  pronator  radii  teres  muscles,  while  the  upper  fragment  is 


Fig.  324. — Displaosment  of  the  fragments  in  fractu 
of  the  radius  in  its  lower  third.     (Alter  Gray.) 


1 


*  Packard,  in  Asbhurst's  "  Enoyclopsedia,"  vol.  iv.     William  Wood  &  Co.,  New  York. 


FRACTURES. 


301 


rotated  outward  by  the  biceps.  Wlien  the  bone  is  broken  below  this 
point  the  lower  fragment  tends  towai'd  the  nlna.  The  upper  may  be 
held  out  by  the  biceps,  or  carried  toward  the  ulna  if  the  pronator  radii 
teres  is  contracted  (Fig.  324). 

Treatment. — The  position  which  renders  the  approximation  of  the 
fragments  most  easy  is  that  of  supination  ;  but  in  this  position  the  two 
bones  are  almost  in  apposition,  and  the  danger  of  osseous  union  between 
them,  with  loss  of  lateral  motion,  is  increased.  For  this  reason  it  is  safer 
to  fix  the  limb  half  way  between  supination  and  pronation  (with  the 
thumb  pointing  upward).  (The  application  of  the  splint  is  the  same  as 
for  fracture  of  both  bones.) 

Fracture  at  tlie  Carpal  End  of  the  Radius. — Fracture  through  the 
cancellous  expansion  of  the  lower  end  of  the  radius  is  the  most  frequent 
of  all  fractures  ;  that  of  the  clavicle  next  in  order.  The  line  of  fracture 
is  in  general  transverse,  and  within  one  inch  of  the  articular  surface, 
being  usually  nearer  the  anterior  margin  of  the  articular  surface,  and 
running  obliquely  upward,  on  to  the  dorsal  aspect  of  the  bone,  at  a  dis- 
tance varying  from  one  fourth  to  one  inch  above  the  posterior  lip.  In 
very  exceptional  instances  the  posterior  lip  or  rim  is  split  off,  the  line  of 
fracture  leading  from  the  articular  surface  upward,  on  to  the  dorsal 
aspect  of  the  bone  (Barton's  fracture).  The  styloid  process  is  also  occa- 
sionally broken  off,  or,  when  the  violence  of  the  fall  is  great,  the  bone 
may  be  split  in  its  long  axis  by  the  first  impact  of  the  carpus,  and  after- 
V7ard  transversely  fractured  by  the  forced  extension  and  strain  on  the 
anterior  ligaments. 

Though  a  fall  on  the  back  of  the  hand  has  been  known  to  produce  a 
transverse  fracture  of  the  cancellous  expansion  of  the  carpal  end  of  the 
radius  in  a  few  instances,  in  the  vast  majority  of  cases  the  force  is  first 
received  upon  the  palmar  aspects  of  the  fingers  and  the  palm,  with  the 
hand  in  forced  extension. 

The  mechanism  of  this  lesion  is  this :  In  the  act  of  falling,  the  hand 
is  thrown  out,  and  the  force  of  the  fall  is  received  first  upon  the  palm, 
and  chiefly  upon  the  anterior  extremity  of  the  metacarpus,  whence  it  is 
transmitted  backward  to  the  carpus,  and  to  the  anterior  radio-carpal 


Displacement  of  fragments  in  Oollcs's  fracture.     (After  Gray.) 


ligaments.  As  the  extension  is  continued,  the  strain  on  this  ligament  is 
increased,  until  the  bone  begins  to  yield  on  its  anterior  aspect,  close  to 
and  parallel  with  the  i-adial  attachment  of  the  ligament,  and,  as  the  force 


302  A  TEXT-BOOK  ON   SURGERY. 

is  continued,  the  line  of  fracture  travels  upward  and  backward.  The 
same  force  which  produced  the  fracture  by  forced  extension  and  impact 
of  the  body  will,  if  continued,  produce  the  usual  displacement,  causing 
the  lower  fragment  to  ride  backward  upon  the  upper,  and  frequently 
causing  impaction  of  the  compact  posterior  rim  of  the  upper,  into  the 
spongy  substance  of  the  lower  fragment  (Fig.  325). 

The  diagnosis  of  CoUes's  fracture  is  not  difficult.  The  "  silver- fork  " 
deformity,  the  history  of  the  accident,  and  pain  at  the  seat  of  the  lesion, 
point  to  the  character  of  the  fracture.  When  backward  displacement 
occurs  it  will  be  recognized  by  palpation.  Crepitus  may  or  may  not  be 
elicited.  The  hand  is  dii-ected  to  the  radial  side,  and  the  styloid  process 
of  the  ulna  is  unusually  prominent. 

Treatment. — When,  after  careful  examination,  there  is  found  any 
degree  of  displacement  of  the  lower  fragment,  upward  and  backward 
upon  the  upper,  proceed  as  follows  : 

With  the  back  of  the  patient's  hand  turned  upward,  the  operator 
with  one  hand  grasps  the  forearm  in  such  a  way  that,  while  the  radius 
is  firmly  held,  the  thumb  is  immediately  above  the  line  of  fracture. 
With  the  other,  the  hand  of  the  patient  is  grasped  so  that  his  (the  sur- 
geon's) thumb  (or  index-finger,  if  preferred)  presses  firmly  upon  the 
back  of  the  lower  fragment.  The  hand  is  now  carried  strongly  back 
toward  the  dorsal  aspect  of  the  radius  (forced  and  extreme  extension), 
and  while  in  this  position  the  lower  fragment  becomes  unlocked,  and 
may  be  pushed  into  place  by  the  thumb,  while  at  the  same  time  the 
hand,  under  strong  extension,  is  carried  into  the  straight  position.  If 
this  manoeuvre  fails  it  should  be  repeated,  and  under  ether  if  there  is 
great  pain  or  muscutar  resistance.  Too  much  stress  can  not  be  laid 
upon  this.  The  cause  of  so  much  deformity  after  this  accident  is  in 
many  cases  due  to  imperfect  reposition.  If  no  displacement  exists,  ex- 
tension or  the  employment  of  any  force  is  contra-indicated.  In  aged 
patients,  who  have  considerable  impaction,  it  is  not  advisable  to  break 
up  the  impaction,  but  deformity  and  impaired  usefulness  should  be 
prognosticated.  In  cases  with  little  or  no  displacement  and  deformity 
all  extension  or  manipulation  should  be  abstained  from. 

In  many  instances,  however,  deformity  will  inevitably  remain.  The 
shortening  which  may  result  from  the  accident,  or,  in  the  young,  the 
injury  to  the  epiphysis,  which  may  retard  the  growth  of  the  bone  in  its 
long  axis,  causes  a  deflection  of  the  hand  to  the  radial  side,  and  an  ab- 
normal projection  of  the  styloid  process  of  the  ulna.  When,  as  in  some 
exceptional  instances,  the  radio-ulnar  ligaments  are  torn,  and,  as  de- 
scribed by  Prof.  Moore,  of  Rochester,  the  tendon  of  the  extensor  carpi 
ulnaris  is  displaced,  the  tendency  to  deformity  is  even  greater.  When 
proper  reduction  is  obtained,  any  dressing  which  keeps  the  parts  at  rest 
will  secure  a  good  result. 

Within  the  last  few  years  a  large  number  of  cases  of  Colles's  fracture 
have  been  treated  after  the  method  described  by  Prof.  Lewis  E.  Pilcher. 
This  dressing  has  been  slightly  modified  since  it  was  first  made  public. 
The  results  have  been  very  satisfactory.     It  is  as  follows  : 


FRACTURES. 


303 


Roll  two  pieces  of  a  bandage,  two  inches  and  a  half  wide,  into  a  com- 
press about  as  thick  as  the  little  iinger.  After  the  reduction,  place  one 
along  the  inner  aspect  of  the  ulna,  extending  from  the  anterior  margin 
of  the  carpus  upward,  the  other  exactly  parallel  with  this,  along  the 
outer  border  of  the  radius,  over  its  styloid  j)rocess.     While  these  are 


Fio.  326. — Plaster-of-Paris  dressing  for  Colles's  fracture. 

held  firmly  in  position,  secure  them  by  strips  of  adhesive  plaster,  one 
inch  in  width,  wound  securely  around  the  wrist  and  arm,  from  the  lower 
end  of  the  carpus  to  the  end  of  the  compresses.  The  hand  and  arm  are 
carried  in  a  sling.  The  dressing  may  be  changed  in  two  or  three  weeks. 
Gentle  and  careful  motion  of  the  fingers  should  be  made  daily,  but  it  is 
advisable  not  to  move  the  wrist  until  about  the  end  of  the  second  week. 
The  dressing  should  be  worn  about  four  weeks. 

Another  method  is  to  envelop  the  forearm  and  hand,  as  far  as  the 
metacarpo- phalangeal  articulation,  in  a 
plaster-of- Paris  dressing.  In  this  treat- 
ment, after  reposition  of  the  fragments, 
the  hand  should  be  given  a  considerable 
declination  to  the  ulnar  side.  If  it  is 
desired  to  examine  the  condition  of  the 
fracture,  the  plaster  may  be  cut  on  the 
ulnar  and  radial  sides,  and  reapplied  as 
a  modified  Bavarian  splint  (Fig.  826). 

Prof.  Hamilton's  method  is  as  fol- 
lows :  A  wooden  splint,  made  from  a 
box-top  or  shingle,  is  shaped  to  extend 
from  a  half  inch  in  front  of  the  elbow- 
joint  to  the  metacarpo-phalangeal  artic- 
ulation. Its  breadth  is  equal  to  that  of 
the  arm  at  its  widest  part.  This  splint 
is  thrust  into  a  muslin  sack  (the  seam 
of  which  is  kept  away  from  the  arm), 
and  is  stuffed  moderately  full  of  cotton, 
wool,  or  hair.  The  packing  should  be 
a  little  thicker  in  the  hollow  of  the  palm  and  just  abo-^e  the  lower  end  of 
the  upper  fragment.  A  straight  dorsal  splint  may  also  be  employed.  It 
is  stuffed  in  the  same  manner  as  the  other,  leaving  the  packing  a  little 


Fig.  327. — (After  Hamilton.) 


304  A  TEXT-BOOK   ON  SURGERY. 

thicker  just  over  the  carpus.  After  the  fragments  are  reduced,  the  splints 
are  applied,  and  held  in  place  by  bandages,  as  shown  in  Fig.  327. 

Fracture  of  the  styloid  process,  and  longitudinal  fracture,  should  be 
treated  by  the  modified  Pilcher  dressing. 

In  fractures  of  both  bones  of  the  forearm  proceed  as  follows  :  Pre- 
pare two  splints  of  thin  board,  one,  the  posterior,  to  extend  from  with- 
in one  inch  of  the  olecranon  to  the  ends  of  the  fingers  ;  the  anterior  to 
extend  from  the  elbow  to  the  carpus  ;  both  wider  than  the  forearm  at 
every  point.  Pad  these  with  some  soft  material,  considerably  thicker  in 
the  center  than  elsewhere,  to  serve  as  an  interosseous  pad.  Wrap  each 
splint  with  a  bandage  to  hold  the  padding  in  place.  An  assistant  grasps 
the  patient's  hand  and  arm  above  the  elbow,  and,  with  the  forearm  at  a 
right  angle  to  the  humerus,  held  in  a  position  half  way  between  supina- 
tion and  pronation,  makes  steady  extension,  while  the  operator  makes  a 
careful  reposition  of  the  fragments.  Apply  the  splints  so  that  the  inter- 
osseous pads  will  piish  the  muscles  down  and  between  the  radius  and 
ulna.  Then  fasten  them  by  a  bandage  made  tight  enough  to  prevent 
slipping.  If,  in  the  course  of  a  few  days,  the  dressing  becomes  loosened, 
it  can  be  tightened  by  applying  an  additional  roller.  The  forearm  is 
carried  in  a  sling.  The  treatment  should  be  continued  for  about  four 
weeks,  when  passive  motion  at  the  elbow,  and  supination  and  pronation, 
should  be  made,  and  the  dressing  readjusted  for  another  week.  This 
simple  dressing  is  sufficient  for  aU  fractures  of  one  or  both  bones  of  the 
forearm  (excepting  Colles's  or  Barton's). 

Compound  fractures  of  the  bones  of  the  forearm  require  fixation  by 
this  method,  and  the  security  of  open  wounds,  free  drainage,  and  strict 
antisepsis. 

Carpus — Metacarpus — Phalanges. — Fractures  of  the  carpus  occur 
from  great  and  direct  violence,  being  almost  invariably  compound.  The 
treatment  should  be  fixation,  rest,  and  drainage  under  antiseptic  precau- 
tions. 

The  metacarpal  bones  may  be  broken  by  direct  violence  or  by  blows 
or  falls  on  their  distal  ends.  This  fracture  is  not  uncommon  with  boxers. 
I  had  under  observation  three  brothers,  professional  pugilists,  each  of 
whom  had  a  metacarpal  fracture,  and  one  of  whom  had  also  a  fracture  of 
the  radius,  all  received  while  sparring.  In  the  young,  in  rare  instances, 
separation  may  occur  at  the  epiphyses,  which  are  at  the  phalangeal  ex- 
tremities of  the  metacarpal  bones  of  the  fingers,  and  at  the  carpal  ex- 
tremity for  that  of  the  thumb.  The  fracture  of  a  metacarpal  bone, 
broken  by  indirect  violence,  is  usually  situated  in  its  middle.  The  acci- 
dent is  recognized  by  pain,  displacement,  or  crepitus.  The  treatment  is 
reduction  by  extension  and  counter-extension,  with  direct  manipulation 
and  the  application  of  an  anterior  sijlint,  padded  and  arched  so  as  to  fill 
the  concavity  of  the  palmar  aspect  of  the  bone,  and  to  extend  to  the 
end  of  the  finger.  A  posterior  splint  is  also  applied,  both  fastened  by  a 
roller.  The  danger  is  from  fixation  of  the  extensor  tendon  as  a  result 
of  inflammation.  Passive  motion  of  the  finger  every  day  wiU  pi^event 
this  result. 


FRACTURES.  305 

Fractures  of  the  Phalanges. — In  the  treatment  of  fractures  of  these 
bones  the  same  principles  are  involved  as  for  the  metacarpus.  The  chief 
precaution  is  to  prevent  stiffening  of  the  finger  from  adhesion  of  the 
tendons  to  their  sheaths.  Passive  motion  should  be  made  as  early  as  the 
sixth  day. 

The  Sternum — Biis — Vertebrce. — The  sternum  may  be  broken  by 
direct  or  indirect  violence.  In  recent  cases  reposition  may  be  effected  by 
pressure,  or  by  lifting  vsdth  an  elevator.  In  the  treatment  of  these  cases 
the  most  perfect  quiet  should  be  enforced.  Necrosis  occasionally  foUows 
this  accident,  necessitating  operative  interference. 

Fracture  of  the  ribs  or  of  their  cartilages  may  result  from  (1)  indirect 
violence,  as  a  blow  upon  the  sternum ;  (2)  from  a  direct  injury  ;  or  (3) 
from  muscular  contraction. 

The  longer  ribs  are  most  liable  to  fracture.  When  the  force  is  applied 
to  the  sternum,  the  break  most  frequently  occurs  at  or  just  anterior  to  the 
middle  of  the  bone. 

The  displacement  is  usually  slight.  Haemorrhage  from  division  of  the 
intercostal  vessels  is  one  of  the  immediate  dangers,  while  localized  inflam- 
mation of  the  parietal  pleura  is  inevitable.  The  diagnosis  will  depend 
upon  pain,  elicited  by  pressure  on  the  bone,  at  a  point  remote  from  the 
fracture,  and  occasionally  by  a  peculiar  click  or  crepitus  felt  by  the  hand 
applied  over  the  lesion  during  a  full  respiratory  act.  The  respiratory 
movement  is  less  free  upon  the  affected  side. 

Treatment. — Fixation  of  the  chest- wall,  as  far  as  is  possible,  is  the 
indication  in  treatment.  To  this  end,  the  affected  side  should  be  shaved, 
and  adhesive  strips,  cut  one  inch  and  a  half  in  width  and  long  enough  to 
reach  from  the  sternum  to  the  vertebral  spines,  are  tightly  applied,  ex- 
tending far  enough  above  and  below  the  broken  rib  to  cover  the  three  or 
four  adjacent  bones.  The  strips  should  overlap  about  one  half  of  their 
width. 

The  body  of  a  vertebra  may  be  broken  by  indirect  violence,  as  a  fall 
from  a  height,  the  patient  striking  on  the  head,  feet,  or  buttocks,  or  the 
bone  may  be  crushed  by  extreme  anterior  flexion  (occasionally  due  to 
muscular  action),  or  by  direct  injury,  with  or  without  penetration.  The 
character  of  the  injury,  pain,  and  symptoms  of  i)ressure  upon  the  cord 
or  nerves  will  lead  to  a  correct  diagnosis. 

The  treatment  is  quiet  in  bed,  with  extension  and  counter-extension 
in  the  earlier  stages,  and  later,  the  plaster  jacket,  with  jury-mast  head- 
extension  for  all  lesions  above  the  tenth  dorsal  vertebra.  Below  this 
point  the  jacket,  from  the  pelvis  to  the  axilla,  will  suffice. 

In  the  case  of  the  patient  from  whom  the  accompanying  cut  (Fig. 
328)  was  taken  there  was  a  fracture  at  the  dorso-lumbar  junction, 
which  involved  the  eleventh  and  twelfth  dorsal,  and  fii'st  lumbar  ver- 
tebrae. There  was  a  sharp  knuckle  at  the  last  dorsal  and  first  lumbar 
spines.  He  was  injured  by  an  elevator  descending  upon  him  and  vio- 
lently flexing  the  spine.  Paraplegia  resulted,  with  incontinence  of 
faeces  and  urine.  I  treated  him  by  extension  and  the  plaster- of- Paris 
Jacket.     The  symptoms  of  paralysis  gradually  disappeared,  and  now,  ten 

20 


306 


A  TEXT-BOOK   ON  SURGERY. 


years  after  the  accident,  he  walks  well,  and  does  not  suffer  from  incon- 
tinence. 

Fracture  of  the  articular  processes  is  of  less  frequent  occurrence. 

This  accident  results  from  extreme 
extension  (dorsal),  or  may  occur  from 
direct  or  indirect  violence. 

When  the  spinous  processes  are 
broken,  the  lesion  may  occur  near  the 
extremity,  but  more  frequently  the 
laminated  expansion  is  the  seat  of 
fracture. 

The  indications  in  all  forms  of  in- 
jury to  the  vertebral  column  are  to 
relieve  pressure  upon  the  cord  and 
nerves,  and  insure  all  possible  fixa- 
tion. While,  from  the  anatomical 
construction  of  the  spinal  column, 
extension  is  limited  and  difficult  of 
accomplishment,  yet  it  may  be  ob- 
tained in  a  sufficient  degree  to  re- 
lieve the  injured  structures  from  the 
greater  part  of  the  superincumbent 
weight.  W  hen  the  bodies  are  injured, 
dorsal  extension  throws,  in  part,  the 
weight  from  the  spongy  bodies  on  to 
the  compact  processes.  When  the 
plaster  jacket  can  not  be  worn,  Taylor's  or  Shafer's  brace  may  be  em- 
ployed with  advantage. 

Fractures  of  the  sacrum  are  rare,  and,  when  occurring,  are  due  to 
direct  violence  by  penetrating  bodies,  or  to  falls  from  such  heights  that 
other  and  serious  complications  render  the  prognosis  grave. 

jSTo  treatment  except  enforced  quiet  is  called  for  primarily.  When 
ostitis  and  necrosis  occur  as  a  result  of  comminution,  operative  interfer- 
ence may  be  required. 

Fracture  of  the  coccyx,  with  displacement  forward,  is  not  uncommon. 
The  accident  occurs  from  a  fall  or  blow  directly  upon  the  tip  of  the  spine. 
The  symptoms  are  those  of  pressure  upon  the  rectum,  causing  difficult 
defecation,  proctitis,  and  at  times  fissure  or  ulcer.  Pain  is  always  pres- 
ent, and  is  due  to  infiammation  as  well  as  pressure  upon  the  fifth  sacral 
and  coccygeal  nerves  (coccyodynia).  The  only  treatment  is  removal  of 
this  bone,  which  is  almost  always  followed  by  relief. 

The  incision  is  made  over  the  bone,  in  the  posterior  median  line,  the 
muscular  attachment  being  divided  close  to  the  bone.  Care  must  be 
taken  to  avoid  wounding  the  posterior  plexus  of  veins,  or  the  rectum. 

The  wound  may  be  sewed  in  its  upper  portion,  leaving  the  lower  end 
open  for  drainage. 

Os  Innominatum. — Though  rarely  fractured  as  compared  with  other 
portions  of  the  skeleton,  the  ilium,  ischium,  or  pubes  may  be  broken 


Fig.  323.— Fracture  of  the  vertebras. 


FRACTURES.  307 

singly,  or  all  may  be  involved  in  a  common  lesion  at  the  acetabulum. 
The  force  causing  the  fracture  may  be  directly  applied,  or,  less  frequently, 
by  an  indirect  blow,  as  a  fall  on  the  foot  or  great  trochanter,  in  which  the 
head  of  the  femur  may  be  driven  into  the  a,cetabulum  with  such  violence 
as  to  cause  fracture. 

When  the  fracture  is  confined  to  the  iliac  crest  the  diagnosis  will  be 
determined  by  pretematiu'al  mobility,  crepitus,  and  pain,  in  conjunction 
with  the  history  of  the  case.  "When  the  bones  of  the  deeper  basin  are 
broken,  exploration  by  the  rectum  or  vagina  will  be  necessary. 

The  treatment  demands  reposition  and  rest.  When  the  acetabulum 
is  involved,  extension  to  the  foot  and  leg  (Buck's  method),  with  the  foot 
of  the  bed  elevated,  should  be  practiced.  When  possible,  the  bed  should 
be  so  arranged  that  defecation  may  be  accomplished  without  lifting  the 
pelvis.  A  modification  of  Crosby's  fi-acture-bed  would  answer  this  pur- 
pose well.  Fixation  of  one  or  both  thighs,  including  the  pelvis  and  lower 
portion  of  the  abdomen  and  spine,  could  be  well  effected  by  surround- 
ing these  parts  with  a  plaster-of-Paris  dressing.  The  prognosis  will  de- 
pend, in  great  part,  upon  the  extent  of  the  injury  sustained  by  the  pelvic 
viscera. 

Fractures  of  the  femur  may  be  best  studied  in  three  groups,  viz. :  (1) 
of  the  upper  extremity  (including  the  neck  and  trochanter) ;  (2)  of  the 
shaft ;  (3)  of  the  lower  or  condyloid  extremity. 

Fracture  of  the  neck  of  the  femur  may  take  place  wholly  within, 
partly  within  and  partly  without,  or  wholly  outside  of  the  capsule.  This 
accident  rarely  occurs  in  the  young  and  middle-aged.  It  is  a  lesion  of 
old  age,  and  women  suffer  more  than  men.  The  anatomical  cause  is 
chiefly  a  condition  of  senile  rarefaction,  which  begins  usually  about  the 
fiftieth  year.*  It  has  been  demonstrated  that  the  change  in  the  relation 
of  the  axis  of  the  neck  to  that  of  the  shaft  in  the  aged  is  not  enough  to 
account  for  the  gTeater  prevalence  of  this  accident  in  the  old,  nor  is  there 
a  marked  diminution  of  the  animal  constituents  of  bone  at  this  time  of 
life.     The  change  is  one  of  senile  ati'ophy. 

Fractnre  of  the  neck  of  the  femur  is  usually  caused  by  force  trans- 
mitted from  below  upward,  and  along  the  shaft  of  the  femur.  In  many 
instances  the  accident  is  trivial.  The  specimen  shown  in  Figs.  329  and 
330  was  taken  from  a  patient  who  broke  her  femur  while  in  the  act  of 
kneeling  in  church,  f  It  has  been  known  to  occur  even  while  turning 
over  in  bed.  The  line  of  fracture  may  be  at  any  part  of  the  neck,  and  in 
exceptional  cases  is  through  the  epiphysis.  When  the  fracture  is  near 
the  trochanteric  line,  or  when  these  tuberosities  are  involved,  it  is  usual- 
ly the  result  of  direct  violence — that  is,  a  fall  or  blow  upon  the  hip. 

The  diagnosis  of  fracture  of  the  neck  of  the  femur  may  be  determined 
by  a  study  of  the  history  and  the  symptoms.     If,  after  a  fall  upon  the 

*  Prof.  L.  A.  Stimson,  "  Treatise  on  Fractures."     Henry  0.  Lea's  Son  &  Co. 

t  This  patient  was  treated  by  Dr.  Selden,  of  iforfolk,  Va.,  and,  from  the  history  of  the  ease, 
together  with  the  appearance  of  the  specimen,  I  consider  it  an  intracapsular  fracture,  with 
osseous  union.  Prof.  F.  H.  Hamilton,  to  whom  I  showed  the  specimen,  considered  it  rather  a 
condition  of  senile  atrophy. 


308 


A  TEXT-BOOK   ON  SURGERY. 


foot  or  knee,  or  directly  upon  the  trochanter,  there  results  pain  in  the 
hip,  eversion  of  the  foot,  loss  of  function  in  the  member,  shortening, 


and  crepitus,  fracture  at  the  neck  is  probable.     These  symptoms  are, 
however,  not  always  present.     Pain  is  the  most  constant,  eversion  is  the 

rule,  inversion  the  ex- 
ception, in  about  the 
proportion  of  eight  to 
one.  The  turning  out- 
ward of  the  leg  and  foot 
is  probably  due  to  grav- 
ity, and  when  inversion 
occurs  it  is  due  to  a 
peculiarity  in  the  lock- 
ing or  overlapping  of 
'1°L^  the  fragments.  Loss  of 
function  is  not  always 
'''^"  entire,  for  in  some  in- 
stances— and  very  prob- 
ably in  impacted  fract- 
ures—  the  patient  has 
been  known  to  walk 
a  considerable  distance 
upon  the  limb  after  the 
fracture.  This  is,  how- 
„,.,,.,  ^  ^,    ^         .  ■   J.    .       *     ever,  a  rare  occurrence. 

-Showing  the  displacement  of  the  frasrinentg  m  fracture  of  '  •  ■       t    ^ 

the  neck  of  the  femur.     (After  Gray.)  Shortening    IS    deter- 


FRACTURES. 


309 


mined  by  comparative  measurement  of  the  two  sides,  from  the  ante- 
rior superior  spine  of  the  ilium  to  the  inner  malleolus.  The  internal 
malleoli  should  be  made  to  touch,  and  should  be  directly  in  a  line 
with  the  symphysis  pubis,  umbilicus,  and  interclavicular  notch.  The 
end  of  the  tape  should  be  held  on  the  thumb-nail,  and  pressed  well  into 
the  notch,  just  under  the  anterior  superior  spine.  It  is  then  carried 
along  the  inner  side  of  the  thigh,  knee,  and  leg,  to  the  under  edge  of 
the  inner  malleolus.  The  degree  of  shortening  will  vary  from  one  fourth 
of  an  inch  up  to  two  or  more  inches.  The  occasional  normal  inequality 
in  the  length  of  the  two  lower  extremities  should  not  be  lost  sight  of. 
This  varies  from  one  eighth  to,  in  some  instances,  as  much  as  one  inch 
and  over.  To  determine  that  the  shortening  is  between  the  trochanter 
and  the  acetabulum,  apply  Nelatori's  test ;  a  line  drawn  from  the  tuber- 
osity of  the  ischium  to  the  anterior  superior  spine  of  the  ilium  passes 
over  the  upper  surface  of  the  great  trochanter.  The  distance  the  tip  of 
the  trochanter  may  be  above  this  line  will  give  the  degree  of  shortening. 
Bryant's  test  is,  with  the  patient  resting  upon  the  back,  the  legs  parallel 
and  extended,  to  drop  a  line  from  the  anterior  superior  spine  and  to 
measure  the  distance  between  this  line,  at  its  nearest  point  to  the  tro- 
chanter and  this  tuberosity.  If  the  fracture  is  above  the  trochanter  the 
tuberosity  "will  be  found  nearer  the  line  than  on  the  sound  side. 

Crepitus  can  not  always  be  obtained.  In  the  cases  of  impaction  it  is 
not  possible  vdthout  the  employment  of  force  sufficient  to  unlock  the 
fragments,  and  in  many  cases  of  fracture  above  the  trochanteric  line, 
without  impaction,  crepitus  is  not  felt.  Any  unnecessary  manipulation 
of  the  hip  is  contrary  to  the  best  rules  of 
practice,  and  an  effort  to  elicit  crepitus 
should,  therefore,  not  be  made. 

It  is  difficult,  and  at  times  impossible, 
to  determine  at  what  particular  portion  of 
the  neck  the  fracture  has  occurred.  Prac- 
tically it  makes  little  difference,  as  the 
treatment  is  the  same. 

Treatment. — Rest  in  the  dorsal  decu- 
bitus, with  fixation  of  the  pelvis  and  the 
affected  limb,  are  the  immediate  indica- 
tions. To  secure  fixation,  extension  in  a 
limited  degree  is  desirable.  To  obtain 
this,  place  the  patient  upon  a  hard  mat- 
tress. If  the  bed  is  too  soft  and  yielding, 
place  wide  boards  underneath  the  top  mat- 
tress in  order  to  hold  it  smooth  and  firm. 
Elevate  the  foot  of  the  bedstead  from  six 
to  ten  inches,  by  placing  the  legs  at  this 
end  upon  blocks  of  wood  or  bricks.  Cut 
two  strips  of  strong  adhesive  plaster  (Maw's  moleskin  is  preferable) 
about  two  inches  wide  and  long  enough  to  extend  from  the  hip  to  be- 
yond the  sole.     Lay  one  of  these  upon  the  inner  and  outer  surface  of  the 


Fig.  332. — Fracture  of  the  neck  of  tte 
femur,  with  impaction.     (Bigelow.) 


310 


A  TEXT-BOOK   ON   SURGERY. 


thigli  and  leg,  exactly  opposite  eacli  other,  and  hold  them  in  place  by 
a  well-adjusted  roller.  The  strips  can  be  more  nicely  applied  if  they  are 
partially  divided  with  the  scissors,  in  a  dii-ection  upward  and  inward,  at 
intervals  of  about  two  inches.  When  within  four  inches  of  the  ankle 
the  bandage  is  interposed  between  the  strips  and  the  integument.  In 
order  to  prevent  pressure  upon  the  malleoli,  a  stick  about  six  inches  in 
length  is  placed  between  the  ends  of  the  adhesive  strips,  and  the  exten- 
sion-weight is  attached  to  this. 

A  piece  of  board  provided  with  a  pulley  is  next  fastened  to  the  foot  of 
the  bed,  so  that  the  tip  of  the  pulley  will  be  on  a  level  with  the  malleoli. 
The  weight  will  vary  from  two  or  three  up  to  eighteen  xiounds.  A  pound 
for  every  year  of  life  up  to  eighteen  is  the  rule  ;  but  this  is  too  much  for 
fracture  above  the  trochanter.  About  ten  pounds  is  sufficient  for  all 
ordinary  cases.  Shot  in  a  bag,  or  smoothing-irons,  are  usually  employed 
for  the  extension- weight,  which  is  tied  to  the  string  (Fig.  333).     The  pa- 


tient's body  serves  as  the  counter-extending  force,  the  gravitation  toward 
the  head  of  the  bed  being  about  counteracted  by  the  weight  attached  to 
the  foot.  Additional  benefit  and  comfort  may  be  obtained  by  laying 
small,  long  bags,  filled  with  sand,  on  either  side  of  the  thigh  and  leg. 
When  the  limb  tends  too  strongly  to  outward  rotation  (or  inversion) 
this  may  be  corrected  by  the  sand-bags,  or  by  Prof.  Hamilton's  long 
splint,  which  is  shown  in  Fig.  333,  and  which  is  tied  by  strips  of  bandage 
from  the  axilla  to  the  ankle.  The  foregoing  is  practically  Buck's  ex- 
tension, to  which  may  be  added  Hamilton's  long  splint. 

In  some  instances  it  may  be  found  advantageous  to  use  Volkmann's 
sliding  foot-piece,  seen  in  Fig.  334.  This  consists  of  a  posterior  splint' 
for  the  leg,  to  which  is  attached  a  foot-piece  having  the  angle  shown  in 
the  cut.  This  splint  should  be  perforated  for  the  heel,  and  rest  upon  two 
cross-bars  of  wood,  which  in  turn  slide  up  and  down  on  a  rectangular 
frame.     Upon  the  upper  edge  of  these  parallel  bars  a  tongue  is  cut,  and 


FRACTURES. 


311 


Fig.  334. — Volkmann's  sliding  fbot-pieoe. 


a  corresponding  notch,  or  groove  in  the  cross-bars.  This  apparatus  is 
complicated  and  will  rarely  be  needed.  Buck's  extension,  ^rtith  Hamil- 
ton's long  splint,  or  preferably  the  sand-bags,  wUl  meet  almost  every  re- 
quirement, and  give 
the  greatest  satis- 
faction. 

In  order  to  pre- 
vent the  bed-cloth- 
ing from  coming  in 
contact  with  the 
fractured  limb,  wire 
screens  (Figs.  335, 
336)  may  be  em- 
ployed. In  some 
instances  plaster  of 
Paris  may  be  used ; 
but  this  method  of 
treating  fractures 
above  the  trochan- 
ter is  now  rarely 
employed. 

The  most  easily 
managed  and  simply  constructed  apparatus  for  making  the  necessary 
extension  and  counter-extension,    in  applying  the  fixed   dressing  for 
fractures  of  the  lower  extremity,  is  made  as  foUows  : 

Into  each  end  of  a  ta- 
ble, about  five  feet  long, 
two  holes  are  bored,  and 
into  these  two  perj)endic- 
ular  pieces  are  fitted,  two 
feet  long  and  about  two 
inches  in  diameter,  while 
a  strong  horizontal  bar 
connects  the  two  upper 
ends.  One  of  these  up- 
rights is  smoothed,  round- 
ed, and  padded,  to  pre- 
vent injury  to  the  peri- 
nfeum. 

The  foot  of  the  injured 
side  being  nicely  band- 
aged, the  patient  is  placed 
upon  the  table,  astride 
the  padded  upright  (Fig. 
337),  with  the  perineeura  against  it,  and  is  suspended  by  a  strap  passed 
over  the  horizontal  bar  and  underneath  the  sacrum,  being  elevated  from 
the  table  sufficiently  to  allow  free  manipulation  of  the  bandages  under 
the  back.     The  head  and  shoulders  are  supported  upon  pillows,  the  foot 


Fio.  336.— (Alter  Esmarch.) 


312 


A  TEXT-BOOK   ON   SURGERY. 


of  the  uninjured  limb  rests  upon  a  stool,  a  clove-hitcli  or  double  loop  is 
thrown  around  the  ankle,  and  to  this  a  block  and  pulley  is  attached,  the 
opposite  end  of  which  is  fastened  to  the  wall.     Extension  is  then  applied 

unto,  by  measure- 
ment from  the  ante- 
rior superior  spinous 
process  of  the  ilium 
to  the  lowest  point 
of  the  inner  malleo- 
lus, the  two  legs  are 
found  to  be  of  the 
same  length.  The 
pelvis,  thigh,  and  leg 
are  then  covei'ed  with 
a  dry  roller,  or  a 
trousers' leg,  or  piece 
of  soft  blanket,  and 
the  plaster  rollers 
Fig.  337.  applied.     Accessory 

splints  of  zinc,  cop- 
per, tin,  or  hoop-iron  may  be  worked  in  with  the  plaster  bandages  if 
desired. 

The  prognosis  in  this  class  of  cases  should  always  be  guarded.  Use- 
ful limbs  result  in  a  large  majority  of  cases,  but  the  function  of  the  hip 
is  not  often  fully  restored. 

Fracture  of  the  Trochanter.  —  Separation  of  the  great  trochan- 
ter is  a  rare  accident.  The  cause  is  direct  violence.  A  diagnosis  must 
rest  upon  independent  mobility  of  the  tuberosity,  with  crepitus. 
The  treatment  should  be  fixation,  firm  compression  by  bandages,  and 
rest. 

Fracture  through  the  Trochanters. — Fracture  through  the  trochan- 
ters is  also  comparatively  of  rare  occurrence.  The  diagnosis  may  be 
determined  by  shortening,  crepitus,  pain,  and  loss  of  symmetry  and  func- 
tion. A  strong  diagnostic  feature  is,  that  a  portion  of  the  trochanter  may 
remain  attached  to  the  neck.* 

The  treatment  does  not  differ  from  that  just  given.  The  prognosis  is 
more  favorable  as  to  restoration  of  function.  Occasionally  enormous 
exostosis  occurs  after  fracture  at  this  locality. 

Fractures  of  the  Shaft. — The  shaft  of  the  femur  is  usually  broken  by 
direct  violence,  or  indirectly  by  a  force  transmitted  from  below  upward. 
In  exceptional  instances  the  fracture  is  caused  by  muscular  contraction 
alone.  The  line  of  fracture  is  generally  oblique,  and  the  displacement  is 
determined  chiefly  by  the  direction  of  this  line.  In  complete  fracture 
overlapping  is  the  rule.  When  the  break  is  in  the  ujiper  portion  the 
lower  fragment  is  drawn  up  by  the  long  muscles  extending  from  the 
pelvis  to  the  neighborhood  of  the  knee-joint,  and,  as  shown  in  Fig.  338, 


*  Prof.  L.  A.  Stimson,  op.  cit. 


FRACTUEES. 


313 


the  upper  fragment  is  usually  rotated  outward  by  the  external  rotators, 
and  tilted  up  and  to  the  front  by  the  psoas  and  iliacus.  When  the  fract- 
ure is  near  the  knee-joint  the  lower  fragment  is  tilted  backward  by  the 
action  of  the  gastrocnemius,  popliteus,  and  plantaris  muscles.  The  up- 
per fragment  is  acted  upon  in  a  milder  degree  by 
the  same  muscles  that  caused  its  displacement  in 
the  higher  fracture  (Fig.  339). 

Fractures  at  the  condyles  may  include,  trans- 
verse fracture  near  the  epi- 
physeal line,  or  through  the 
epiphysis  ijroper ;  transverse 
fracture,  with  a  split  into  the 
intercondyloid  notch  ;  or  one 
or  the  other  condyles  may  alone 
be  broken  off. 

The  diagnosis  of  fracture 
of  the  shaft  of  the  femur  is  not 
difficult,  as  a  rule.  Preternat- 
ural mobility,  crepitus,  pain, 
and  shortening  will  usually  de- 
termine the  character  of  the 
injury.  When  the  joint  is  in- 
volved, in  addition  to  the  usual 
symptoms  of  fracture  the  knee 
becomes  much  swollen. 

Treatment. — In  the  treat- 
ment of  all  fractures  between 
the  trochanters  and  the  knee- 
joint  the  choice  rests  between 
the  method  by  Buck's  extension  and  the  plaster- 
of-Paris  dressing.  In  general  the  first  method  is 
preferable.  Unless  the  fracture  is  too  low  down, 
the  traction  of  the  adhesive  strips  should  be  upon  the  condyles  as  well 
as  upon  the  leg  below.  Even  when  it  is  determined  to  employ  the  gyp- 
sum fixed  dressing,  it  is  wise  to  defer  its  application  until  after  all 
danger  of  swelling  is  past,  usually  after  from  four  to  eight  days.  When 
the  fracture  is  below  the  middle  of  the  thigh  the  plaster-of-Paris  dress- 
ing may  be  applied  without  anaesthesia.  The  bandages  need  not  extend 
higher  than  the  level  of  the  perinseum.  After  a  few  days  the  patient  may 
move  about  on  crutches.  In  the  higher  fractures  the  same  princiiDles  are 
involved  as  in  fractures  of  the  neck.  When  the  knee-joint  is  involved, 
passive  motion  should  be  commenced  on  the  third  week,  and  continued 
at  intervals  thereafter.  Whatever  method  is  employed,  immobilization 
at  the  seat  of  fracture  should  be  maintained  for  five  or  six  weeks. 

In  fracture  of  the  femur  in  children  the  plaster-of-Paris  dressing  is 
to  be  preferred.  The  reposition  of  the  fragments  should  be  made  un- 
der ansesthesia,  and  the  parts  immediately  immobilized.  This  class  of 
patients  are  not  easily  controlled  and  kept  quiet  by  the  use  of  the  ordi- 


Fio.  339.  —  Displacement 
of  fragments  in  Iract- 
ure  of  the  thigh  in  the 
lower  third.  (Alter 
Gray.) 


Fig.  338.  —  Displaeement  of 
fragments  in  fracture  of 
the  thigh  in  the  upper 
third.     (After  Gray.) 


314 


A  TEXT-BOOK   ON   SURGERY, 


nary  apparatus.*  In  one  instance  of  fracture  at  the  trochanters  in  a  child 
just  delivered,  I  placed  the  extremitj^  in  the  position  assumed  in  utero, 
the  thigh  flexed  on  the  abdomen,  the  leg  flexed  on  the  thigh,  enveloped 
the  parts  with  flannel  bandages,  and  applied  plaster-of-Paris  rollers  from 
the  ankle  to  the  axillae.  The  dressing  vpas  removed  on  the  twenty-first 
day,  and  the  cure  was  perfect.  There  is  no  shortening  or  impairment 
of  function,  and  the  child  walks  and  runs  with  perfect  motion. 

Patella. — Fracture  of  the  patella  may  be  caused  by  violent  contraction 
of  the  quadriceps  extensor  muscle,  or  by  a  blow  or  fall  upon  this  bone, 
or  both  of  these  factors  may  combine  to  cause  this  lesion.  The  line  of 
cleavage  is  usually  transverse,  and  in  the  majority  of  instances  Just  below 
the  middle  of  the  patella.  It  may  be  broken  in  an  oblique  or  longitu- 
dinal direction,  or  in  several  directions  at  once— ^''  stellate  fracture." 

When  muscular  contraction  is  the  chief  or  sole  factor  in  this  break, 
the  line  of  cleavage  is  usually  transverse.  Longitudinal  and  stellate 
fractures  are  the  result  of  direct  violence.  Fracture  of 
the  patella  is  usually  complete,  the  separation  of  the 
fragments  varying  from  a  small  fraction  of  an  inch  up 
to  two  or  more  inches.  The  separation  is  generally  more 
marked  on  the  internal  than  the  external  border.  In 
rare  instances  incomplete  fracture  may  occur,  the  car- 
tilage not  giving  way.  Such  cases  are  scarcely  recog- 
nizable without  exploration,  the  few  recorded  being 
seen  post-mortem.  Fracture  of  the  patella  is  more  fre- 
quent in  men  than  in  women,  and  occurs  mostly  in  the 
decades  from  the  twentieth  to  the  fortieth  years. 

The  diagnosis  may  be  made  from  loss  of  function, 
pain  at  the  seat  of  injury,  and  separation  of  the  frag- 
ments. Inability  to  extend  the  leg,  or  marked  impair- 
ment of  function,  is  always  present.  The  limb  may, 
however,  be  used  to  support  the  body  if  it  is  allowed 
to  fall  into  the  straight  position.  One  of  my  patients, 
with  a  separation  of  three  fourths  of  an  inch,  walked,  unaided,  a  quar- 
ter of  a  mile  immediately  after  the  accident.  Hgemorrhage  between  the 
fragments  occurs  in  all  cases,  and  therefore  communicates  with  the  syno- 
vial membranes,  which  are  interposed  between  the  posterior  surface  of 
the  patella  and  the  general  cavity  of  the  joint,  and,  in  cases  where  the 
separation  is  well  marked  (from  half  to  one  inch  and  over),  it  is  more 
than  probable  that  the  reflection  of  the  synovial  lining,  from  the  lower 
anterior  portion  of  the  joint  below  the  patella  upward  and  forward  to 
the  front  of  the  intercondyloid  notch,  is  torn,  and  that  whatever  of  ex- 
travasation occurs  is  into  the  general  cavity  of  the  joint.  This  occurred 
in  the  only  knee  I  have  opened,  immediately  after  this  fracture.  More 
or  less  effusion  into  the  Joint  follows  in  the  majority  of  cases.  In  longi- 
tudinal and  stellate  fractures  the  separation  is  usually  slight. 

*  In  one  instance,  in  the  case  of  a  child  three  and  a  half  years  old,  with  a  fracture  at  the 
middle  of  the  thigh,  chloroform  narcosis  was  ohtained  during  natural  sleep,  the  child  not  be- 
coming conscious  while  passing  under  the  influence  of  the  ansesthetio. 


Fig.  340. —Displace- 
ment of  fragments 
in  fracture  of  the  pa- 
tella. (Alter  Gray.) 


FRACTURES.  315 

Treatment. — A  patient  vdtli  a  broken  knee-pan  should  be  immediately 
put  to  bed,  in  the  dorsal  decubitus,  the  affected  limb  kept  straiglit,  and 
the  foot  and  leg  elevated  on  pillows.  In  case  of  swelling  and  inflamma- 
tion at  the  knee,  cold  cloths  or  the  ice-bag  should  be  applied.  The 
mechanical  treatment  should  commence  at  once. 

A  posterior  splint  is  made  to  extend  from  near  the  heel  to  the  gluteal 
fold.  Shellac-board  is  best  suited  for  this  purpose,  but  sole-leather, 
gutta-percha,  or  a  piece  of  plank  will  suffice,  if  these  lighter  articles  can 
not  be  obtained.  If  either  of  the  first  three  articles  is  employed,  the  i^iece 
should  be  cut  wide  enough  to  envelop  fi'om  one  half  to  two  thirds  of  the 
circumference  of  the  limb.  Three  inches  above  and  below  the  center  of 
the  knee-joint  a  tongue,  one  inch  wide  and  two  inches  long,  should  be  cut, 
and  turned  out  so  that  the  attached  end  is  nearest  the  joint.  The  splint 
is  dipped  in  warm  water  \intil  soft  enough  to  be  molded  to  the  part,  when 
it  is  lined  with  a  sheet  of  absorbent  cotton  and  applied  on  the  posterior 
aspect  of  the  limb.  The  cotton  or  padding  material  should  be  consider- 
ably thicker  opposite  the  popliteal  space,  in  order  to  prevent  complete 
extension  of  the  leg.  Secure  the  upper  and  lower  ends  by  tiirns  of  the 
roller  thrown  around  the  thigh  and  leg,  and  next  begin  the  oblique 
or  approximating  turns  by 
carrying  a  flannel  bandage 
around  the  leg,  so  that  it 
catches  behind  the  lower 
tongue,  whence  it  is  carried 
obliquely  upward  above  the 
upper  fragment,  across  the 
quadriceps,  and  back  to  the 
starting-point.  This  is  con- 
tinued until  the  upper  frag-      x-       .,     o     ,  .    ^  .  ,,        „ 

^  '-  ^  ill.    u41  — Uamuton  o  apparatu-.  tor  fracture  ot  the  patella 

ment  is  brought  into  appo-  (Hamilton ) 

sition  with  the  lower.     For 

the  lower  fragment   the  bandage  is   made   to  catch  behind  the  upper 

tongue  iipon  the  splint.      When  the  fragments  are  ai^proximated  the 

entire  limb  is  invested  by  the  roUer. 

After  the  dressing  is  applied  the  same  position  is  maintained  for  two 
weeks.  The  portion  of  the  bandage  immediately  over  the  fracture  should 
be  opened  on  the  fifth  or  sixth  day,  and  a  careful  inspection  made,  in 
order  to  detennine  whether  the  roller  has  slipped  and  re-separation  oc- 
curred. If  the  bandage  is  at  all  loose  it  should  be  tightened,  but  never 
drawn  so  tightly  that  it  produces  any  discomfort. 

This  inspection  should  be  repeated  every  five  or  six  days,  but  the 
splint  is  never  taken  off  until  the  fourth  week,  when  passive  motion  at 
the  knee-joint  shoiild  be  made.  In  doing  this  the  surgeon  should  grasp 
the  patella  between  the  thumbs  and  fingei's,  in  order  to  hold  the  frag- 
ments firmly  in  contact,  and  while  thus  held  should  have  an  assistant 
move  the  leg  back  and  forth,  not  flexing  it  for  the  first  time  more  than 
15°  or  20°.  This  should  be  repeated  each  week  until  the  ninth  week,  and 
twice  a  week  after  this  for  the  next  two  or  three  months.     After  the  first 


316  A  TEXT-BOOK   ON   SURGERY. 

two  weeks  the  patient  may  be  allowed  to  sit  up  in  bed,  or  to  be  moved 
tipon  a  sofa  or  chair  about  the  room.  After  four  weeks  he  may  be  per- 
mitted to  move  about  on  crutches.  Except  when  passive  motion  is  being- 
made,  the  splint  should  be  worn  night  and  day  for  the  first  ten  weeks 
after  the  injury.  After  this  it  may  be  removed  after  retiring  for  the 
night  and  adjusted  before  rising,  the  posterior  splint  gradually  short- 
ened, and  a  figure-of-eight  bandage  about  the  knee  should  be  worn  for  six 
months,  to  prevent  a  re-separation.  After  this  a  strong  leather  flexion- 
check  should  be  worn  for  the  next  twelve  months.  After  eighteen 
months  of  careful  watching,  such  a  ligamentous  union  will  not  give  way, 
except  under  conditions  which  would  break  the  bone.  In  two  cases 
which  came  under  my  observation  (the  i)atients  both  males,  one  forty 
and  the  other  about  fifty-five  years  old)  the  ligamentous  union  was  so 
strong  that,  several  years  after  the  first  accident,  they  suffered  a  second 
injury,  and  the  upper  fragment, parted  transversely,  the  ligament  hold- 
ing intact.  The  foregoing  method,  which  is  practically  that  of  Prof. 
Hamilton,  is  by  far  the  most  preferable  treatment  for  this  injury. 

Many  innovations  have  been  made  in  the  treatment  of  this  fracture, 
some  of  which  are  unnecessary,  others  unjustifiable.  Among  the  former 
may  be  mentioned  aspiration  of  the  efi'usion  into  the  joint  and  between 
the  fragments.  This  should  only  be  done  when  the  capsule  is  distended 
in  an  extraordinary  'degree.  The  most  unjustifiable  method  of  treatment 
ever  introduced  in  this  fracture  Is  that  of  opening  into  the  joint  and 
wiring  the  fragments  together.  Unjustifiable  because,  first  of  all,  it  is 
dangerous  ;  secondly,  it  is  unnecessary.  A  careful  observance  of  the 
rule  of  practice  just  laid  down  will  secure  a  ligamentous  union,  with 
a  restoration  of  the  function  of  the  extremity,  equally  as  good  in  many 
cases  as  that  enjoyed  before  the  injury,  and  in  the  vast  majority  of 
cases  eqiial  to  all  the  ordinary  requirements  of  the  limb,  and  this  is 
accomplished  without  the  slightest  risk  to  the  patient's  life,  and  with 
no  disturbance  of  his  comfort  beyond  confinement  to  bed  for  two  weeks, 
to  the  room  for  four  weeks,  and  to  his  crutches  and  cane  for  about  six 
months. 

On  the  other  hand,  by  wiring,  although  an  osseous  union  may  be 
obtained,  the  restoration  of  function  is  not  more  complete,  the  confine- 
ment in  bed  is  longer,  and  the  danger  to  life  and  the  integrity  of  the 
part  sufficiently  great  to  deter  the  surgeon  from  employing  this  method 
of  i^ractice. 

In  September,  1881,  induced  by  the  reported  successes  after  this 
operation,  I  wired  a  fractured  patella  on  the  twentieth  day  after  the  ac- 
cident, in  the  case  of  a  woman  twenty  years  old.  The  strictest  antisep- 
tic precautions  were  employed,  and  free  drainage  was  secured.  Osteo- 
arthritis with  destruction  of  the  joint  resulted,  and  the  patient  barely  es- 
caped with  her  life,  the  limb  having  been  amputated  in  the  lower  third 
of  the  thigh.*    Another  patient,  in  the  hands  of  a  New  York  surgeon, 

*  For  a  full  report  of  this  case,  and  a  synopsis  of  other  cases,  see  the  author's  paper  in  the 
"  Medical  Record,"  vol.  xsi,  18&2. 


I 


FRACTURES. 


317 


died  as  a.  result  of  this  operation.  If  the  full  histories  of  all  these  cases 
were  written  I  think  few  surgeons  would  have  the  temerity  to  repeat  the 
procedure. 

The  employment  of  Malgaigne's  hooks  gives  more  pain  and  annoy- 
ance, and  does  not  secure  a  result  at  all  superior  to 
the  conservative  method  just  given. 

The  plaster-of-Paris  method  is  employed  by  some 
operators  ;  but  it  is  not  to  be  preferred  to  the  method 
of  Hamilton.  In  this  procedure  the  fragments  are  ap- 
proximated by  adhesive  strips.  One  piece  is  cut  in 
the  shape  shown  in  Fig.  342,  the  broad  part  of  which 
is  applied  Just  above  the  upper  margin  of  the  upper 
fragment,  and  fastened  here  by  a  roller.  The  entii^e 
limb  is  now  covered  by  a  bandage  which  leaves  ex- 
posed the  two  narrow  strips  of  the  adhesive  plaster. 
Over  this  the  plaster  bandages  are  applied,  strong  trac- 
tion being  made  upon  the  adhesive  strips  in  order  to 
hold  the  fragments  approximated  until  the  gypsum 
hardens.  The  Umb  should  be  enveloped  from  the 
ankle  to  the  perinfeum. 

In  old  fractures,  with  wide  separation  of  the  frag- 
ments and  permanent  loss  of  function  of  the  extensor 
muscles,  the  best  prothetic  apparatus  is  a  strong  leath- 
er shield  worn  around  the  knee.     This  prevents  too  much  flexion,  and 
partly  stiffens  the  joint. 

Many  cases  of  wide  separation,  however,  retain  the  function  of  the 
limb  in  a  remarkable  degree.     In 
a  case  occurring  in  my  practice, 


Fig.  342.— Gauntlet  of 
adhesive  plaster  lor 
exertin-j  traction  on 
the  upper  frairment 
of  a  iractiu'eii  pa- 
tella. 


■% 


Fig.  Si3.  Fig.  344. — Wide  separation  of  fragments  (from  a  to  b). 

with  perteot  function  of  limb. 

from  which  the  two  accompanying  cuts  were  taken,  there  is  a  separation  of 
more  than  three  inches  with  the  leg  flexed  (Fig.  343),  and  nearly  one  inch 


318  A  TEXT-BOOK  ON   SURGERY. 

and  a  half  in  extension  (Fig.  344) ;  yet  tliis  patient  lias  perfect  use  of  the 
limb.  No  approximation  of  the  fragments  was  ever  attempted  in  this 
patient.  He  was  kept  in  bed,  with  the  leg  elevated,  for  six  weeks,  and 
an  ordinary  roller  applied  after  this,  without  any  effort  at  bringing  the 
fragments  together. 

Longitudinal  fractiTres  of  the  patella  should  be  treated  by  fixation  of 
the  muscles  of  the  thigh  and  leg,  and  lateral  approximation  of  the  frag- 
ments by  flannel  bandages,  well  applied  over  a  thin  layer  of  absorbent 
cotton. 

Stellate  fractures,  in  which  the  air  is  not  admitted  to  the  joint,  should 
be  treated  by  Hamilton's  method. 

In  compound  fractures  of  the  patella  in  which  the  joint  is  laid  open, 
the  cavity  of  the  joint  should  be  carefully  drained  and  strict  antisepsis 
employed.  If  the  fragments  are  widely  separated,  and  can  not  be  kept 
in  approximation,  strong  catgut  or  fine  wire  sutures  may  be  employed  to 
hold  them  in  position.     Such  instances  wUl  rarely  occur. 

Leg. — Fracture  of  one  or  both  bones  of  the  leg  occurs  next  in  fre- 
quency to  that  of  the  radius  and  ulna.  The  upper  end  of  the  tibia  is 
usually  broken  by  direct  violence,  although  a  fall  from  a  height  upon  the 
foot  may  produce  a  longitudinal  or  oblique  fracture  communicating  with 
the  joint.  The  separation  sometimes  takes  place  through  the  epiphysis. 
The  most  common  point  of  fracture  is  the  junction  of  the  middle  and 
lower  third.  The  fibula  may  be  broken  at  the  same  level,  or  at  a  point 
removed  from  the  line  of  fracture  in  the  tibia,  or  this  last  bone  alone 
may  be  broken. 

Near  the  ankle-joint  fracture  of  one  or  both  bones  is  not  uncommon. 
While  a  complete  double  fracture  below  the  junction  of  the  middle  and 
lower  third  is  rare,  a  partial  fracture  of  the  tibia  (malleolus)  and  a  com- 
plete break  of  the  fibula  is  comparatively  frequent.  In  this  (Pott's) 
fracture  (called  also  railroad  or  street-car  fracture,  since  it  is  often  caused 
by  jumping  from  a  car  in  motion)  the  foot  is  powerfully  everted,  the 
inner  malleolus  bent  forcibly  inward,  and  the  strain  falls  upon  the  inter- 
nal lateral  ligament  of  the  ankle-joint,  the  internal  malleolus,  the  external 
malleolus,  and  outer  tip  of  the  articular  surface  of  the  tibia.  As  the  force 
is  continued,  either  the  internal  lateral  ligament  or  the  inner  malleolus 
must  yield,  and,  as  usual  in  this  test  between  ligament  and  bone,  the 
latter  yields.  As  a  rule,  the  osseous  rim  is  torn  ofl:  with  the  ligament,  or 
the  entire  malleolus  is  wrenched  off  at  a  higher  point.  The  pressure  upon 
the  inner  aspect  of  the  external  malleolus  forces  this  outward,  and  the 
fibula  above  is  bent  inward  and  usually  breaks  at  between  two  and  three 
inches  above  the  tip  of  the  malleolus.  If  great  force  is  exercised  in  the 
production  of  this  fracture,  the  inferior  tibio-fibular  ligament  may  be  torn 
away,  or,  more  likely,  the  outer  lip  of  the  articular  surface  of  the  tibia 
broken  off.  In  exceptional  instances,  invei'sion  of  the  foot  will  produce 
fracture  of  the  inner  malleolus  by  direct  pressure  of  the  astragalus,  and 
of  the  external  malleolus  or  fibula  by  traction  on  the  external  lateral 
ligament. 

In  fracture  of  the  tibia  alone  the  displacement  will  be  determined  by 


FRACTURES. 


319 


the  direction  of  the  line  of  fracture.  Marked  overlapping  or  displace- 
ment is  prevented  by  the  unbroken  fibula.  In  the  upper  portion,  with  a 
transverse  fracture,  the  deformity  is  slight.  At  the  lower  and  middle 
third  the  obliquity  is  usually  considerable,  and  from  below  upward  and 

backward  (Fig.  345).  The  upper  fragment 
is  tilted  forward  by  the  action  of  the  quad- 
riceps extensor,  and  partly  by  the  pressure 
of  the  upper  end  of  the  lower  fragment, 
which  is  thrown  in  the  same  direction  by 
the  contraction  of  the  sural  muscles  and 
the  consequent  lifting  of  the  heel.     The 


Fig.  345. — Displacement  of  fracrtnents  in 

fracture  of  the  tibia,  near  "the  iunc-  Fio.  346. — Displacement  of  the  fragments  in  Pott's  fracture, 

tion  of  the  lower  and  middle  third.  (After  Gray.) 

(Alter  Gray.) 

deformity  in  Pott's  fracture  is  shown  in  Fig.  346.  In  complete  fracture 
of  both  bones  of  the  leg,  overlapping  and  displacement  are  the  rule. 

Diagnosis. — Fracture  of  the  fibula  alone  may  exist  without  detection, 
although  a  careful  examination,  with  direct  pressure,  will  usually  elicit 
crepitus  or  reveal  the  point  of  fracture  by  abnormal  mobility  and  pain. 
Fracture  of  the  tibia  is  easily  made  out  by  palpation  along  the  spine, 
crepitus,  loss  of  symmetry,  and  pain.  These  symptoms,  together  with 
the  history  of  the  accident,  will  leave  little  room  for  doubt  in  any  case. 
Pott's  fracture  is  recognized  by  the  peculiar  eversion  of  the  foot,  the  ab- 
normal prominence  of  the  internal  malleolus,  pain,  and  loss  of  function. 
Crepitation  of  the  fragments  of  the  malleoli  may  be  elicited,  and  preter- 
natural mobility  in  the  fibula,  at  a  point  two  or  three  inches  above  the 
tip  of  the  outer  malleolus.  In  inversion  with  fracture  the  outer  malleolus 
is  prominent.  Fracture  of  both  bones  is  easily  made  out  by  the  deform- 
ity, abnormal  mobility,  and  crepitation. 

Treatment. —la.  most  cases  of  fracture  of  one  or  both  bones  of  the  leg 
it  is  the  best  practice  to  reduce  the  displacement  by  extension  and  coun- 


320 


A  TEXT-BOOK   ON   SURGERY. 


ter-extension,  and  to  fix  the  part  in  the  position  of  least  discomfort  for 
from  four  to  six  days,  or  until  all  danger  of  swelling  is  past.  After 
this  time  no  method  is  so  satisfactory  as  the  plaster-of-Paris  dressing. 

To  meet  the  first  indication  the  fracture-box  (Fig.  347)  is  a  most  use- 
ful apparatus.     It  consists  of  a  bottom,  a  foot-piece,  and  two  movable 


347.— i'niuturt-box. 


side-pieces.  This  may  be  placed  upon  a  pillow  or  box  to  give  it  a  slight 
elevation,  or  the  apparatus  may  be  modified  after  Petit' s  box  (Fig.  348), 
since  the  position  of  positive  flexion  is  usually  more  comfortable  than 
full  extension. 

If  any  extension  is  needed  it  may  be  secured  by  a  bandage  around  the 
ankle  and  foot,  which  is  also  passed  through  the  holes  in  the  foot-piece. 
In  fixing  the  leg  in  this  fracture-box  the  sides  are  turned  down,  a  thick 


Fig.  348.— Petit'a  fracture-box.     (After  Stimson.) 

layer  of  cotton  or  some  soft  material  arranged  for  the  leg  to  rest  upon, 
and  shaped  to  fit  the  natural  contour  of  the  calf.  The  sides  are  also 
packed,  turned  into  position,  and  fastened.  As  soon  as  the  first  swelling 
subsides,  or  as  soon  as  it  is  evident  that  no  marked  swelling  will  occur, 
the  plaster  of  Paris  should  be  applied.  This  dressing  should  extend  at 
least  half  way  up  the  thigh,  in  all  cases,  in  order  to  fix  the  knee-joint. 
It  is  applicable  to  all  fractures  of  one  or  both  bones,  from  the  Jvuee  down 
to  and  including  the  malleoli.     Extension  can  usually  be  made  from  the 


FRACTUEES. 


321 


heel  and  ankle  by  an  assistant.  A  dry  muslin  or  flannel  roUer  is  first 
applied,  and  the  plaster  bandages  laid  on  over  this.  A  thin  layer  of  ab- 
sorbent cotton  is  at  times  placed  between  the  first  dry  roUer  and  the  leg 
(Fio-.  349).  If  swelling  should  occur,  the  plaster  cast  should  be  split  down 
the  middle  line,  in  front  and  behind,  and  replaced,  but  not  so  tightly.. 
When  such  a  dressing  requires  frequent  removal  it  is  best  to  line  the  cut 


Fig.  349. — Plaster-of-ParU  dressing  in  fracture  of  leg. 


edges  of  the  cast  with  adhesive  strij)s,  and  to  make  hinges  along  the  pos- 
terior seam  out  of  the  same  material.  At  the  end  of  four  weeks  all  splints 
should  be  removed,  passive  motion  made  at  the  knee  and  ankle,  and  the 
apparatus  reapplied  and  worn  for  at  least  two  weeks  more.  Passive 
motion  should  be  repeated  each  week. 

In  applying  the  plaster  in  PoWs  fi'acture  the  eversion  needs  to  be 
overcome  and  the  straight  position  maintained  while  the  gypsum  is  hard- 
ening. To  accomplish  this  a  piece  of  adhesive  plaster  about  two  inches 
wide  is  laid  along  the  fibula  side  of  the  leg,  as  high  as  the  upper  two 
thirds,  extending  down  over  the  external  malleolus,  and  across  the  sole 
of  the  foot  to  the  inner  side.  A  muslin  roller  is  next  passed  around  the 
ankle  over  the  inner  malleolus.  These  tuberosities  should  be  protected 
by  bits  of  absorbent  cotton.  An  assistant  steadies  the  ankle  by  traction 
on  the  roller,  while  the  foot  is  brought  into  straight  position  by  traction 
on  the  adhesive  strip.  The  plaster  is  now  applied,  and  the  foot  held  in 
position  of  slight  over-correction  until  ihe  cast  hardens. 

When  plaster  of  Paris  can  not  be  had,  starch  is  next  in  order,  or 
splints  of  felt,  leather,  book-binder's  board,  metal,  or  wood  may  be  em- 
ployed. 

Compound  fractures  of  the  leg  are  treated  by  immediate  reduction  of 
the  deformity,  by  free  drainage,  and  strict  antiseptic  precautions.  For 
perfect  fixation,  and  at  the  same  time  leaving  the  wound  open  for  irriga- 
tion and  inspection,  the  inteiTupted  or  the  fenestrated  plaster-of-Paxis 
dressing  is  the  most  generally  useful.  If  the  injury  is  slight  and  lim- 
ited, the  fenestrated  dressing  is  preferable.  Extension  is  made  from  the 
foot,  and,  after  reposition  and  drainage  are  secured,  the  plaster  band- 
ages are  applied.  As  soon  as  the  dressing  sets,  windows  large  enough 
to  permit  of  free  inspection  are  cut  immediately  over  the  wound  and 
at  the  points  of  exit  of  the  drainage-tubes  below.  A  wire  loop,  worked 
into  the  plaster  or  tied  around  the  leg  after  hardening  has  taken  place, 
win  serve  as  a  medium  for  suspending  the  limb  at  any  requii'ed  height; 
(Fig.  350). 
21 


322 


A  TEXT-BOOK   ON   SURGERY. 


The  interrupted  plaster  dressing  is  more  difficult  of  aj)plication.  The 
entire  leg  and  foot,  and  half  way  uj)  the  thigh,  are  covered  with  a  dry 
flannel  or  muslin  roller,  which  passes  over  the  wound,  retaining  the  sub- 
limate and  iodoform  gauze  in  place.     A  strong  piece  of  bar-iron,  or  two 


Fig.  350. — Fenestiatcd  plastor-of-P.iris  dressing  for  fix.ition  and  through- 
drainage  m  compound  fractures. 


or  three  thicknesses  of  hoop-iron,  or  a  twist  of  from  four  to  six  ordinary 
telegraph-wires,  is  now  shaped  to  follow  the  outline  of  the  foot  and  leg 
Tip  to  within  three  inches  of  the  wound  and  exits  of  the  drainage-tubes, 
at  which  point  it  is  bent  up  for  several  inches,  and  passes  over  the  wound 
much  like  the  handle  of  a  valise  (see  Fig.  351).  As  soon  as  a  point  three 
inches  above  the  wound  is  reached  it  is  again  made  to  conform  to  the 


shape  of  the  leg  and  thigh.  A  separate  straight  piece  of  iron,  or,  if 
needed,  two  pieces,  about  sixteen  inches  in  length,  are  also  prepared.  A 
layer  of  absorbent  cotton  is  placed  around  the  leg  and  thigh  before  the 
first  bandage  is  applied,  and  over  this  the  plaster  rollers  are  carried, 
above  and  below  the  fracture,  to  within  three  inches  of  the  wound. 
After  several  layers  of  bandage  (generally  three  thicknesses)  have  been 
applied,  this  much  is  allowed  to  harden,  and  ^^l^on  this  the  long  iron 
splint  is  laid,  in  front,  and  the  short  pieces  posteriorly  and  laterally  (out 
of  the  way  of  the  drainage-tubes),  and  are  fixed  by  additional  turns  of 
the  plaster  bandages  and  by  plaster  mortar  worked  in  with  the  hands. 
That  portion  of  the  bar  which  is  shaped  like  the  handle  of  a  valise  should 
be  stiffened  by  Avinding  around  it  several  thicknesses  of  the  plaster  roll- 
ers, and  adding  a  sufficient  quantity  of  plaster  mortar.  Suspension  is 
made  from  the  ends  and  center  of  the  wire. 


FRACTURES.  323 

The  fracture-box  may  be  employed  when  plaster  can  not  be  ob- 
tained. 

Foot. — The  bones  of  the  tarsus  may  be  broken  by  direct  or  indirect 
violence. 

The  diagnosis  is  not  always  easily  made.  The  best  method  of  treat- 
ment is  fixation  with  a  plaster-of-Paris  dressing,  after  all  danger  of  swell- 
ing has  passed.  When  the  os  calcis  is  broken,  and  the  tuberosity  drawn 
up  by  the  sural  muscles,  the  leg  should  be  flexed  well  upon  the  thigh, 
and  the  tarsus  extended  in  order  to  relax  this  group  of  muscles. 

Fracture  of  the  metatarsal  bones  and  phalanges  should  be  treated  in 
the  same  manner  as  the  corresj)onding  bones  of  the  upper  extremity. 

Ununited  Fractures — Fibrous  Union. — In  a  certain  proportion  of 
cases  union  between  the  ends  of  broken  bones  is  delayed  beyond  the  time 
usually  required  for  ossification,  and  may  remain  permanently  ununited. 

The  causes  of  ununited  fracture  are :  (1)  Failure  to  secure  immobility  ; 
(2)  presence  of  muscle,  tendon,  nerve,  or  other  substance  between  the 
fragments  ;  (3)  violent  and  prolonged  inflammation  of  the  broken  bones 
and  the  surrounding  soft  parts  ;  (4)  any  intercurrent  disease  which  inter- 
feres with  nutrition  ;  (5)  a  too  great  separation  of  the  fragments.  If  the 
ends  of  broken  bones  are  not  kept  in  contact,  and  at  the  same  time  im- 
movable, fibrous  union  may  result,  for  by  motion  the  provisional  callus 
is  injured,  and  may  disappear  by  absoi"2Dtion  as  a  result  of  continued 
irritation.  If  the  fragments  overlap,  so  that  no  portion  of  the  broken 
surface  of  one  side  is  in  contact  with  that  of  the  opposite  end,  no  matter 
how  well  adapted  the  dressing  may  be,  muscular  contraction  may  retard 
or  prevent  union. 

The  intervention  of  any  of  the  soft  tissiies,  or  any  foreign  substance, 
may  pi^event  the  formation  of  callus,  and  lead  to  fibrous  union. 

Ostitis  after  fracture  may  lead  to  destruction  of  the  fragments,  and  of 
the  shafts  of  bone,  to  such  an  extent  that  union  can  not  occnr.  Instances 
are  on  record  where,  resulting  from  fracture,  rarefying  ostitis  has  de- 
stroyed the  entire  bone. 

Any  general  condition  of  impaired  nutrition  increases  the  liability  to 
fibrous  union.  Rickets,  osteomalacia,  syphilis,  scrofula,  tuberculosis,  or 
any  acute  febrile  disease  supervening  upon  fracture,  tends  to  interfere 
with  or  to  delay  bony  union  after  fracture. 

When  by  any  reason  the  broken  surfaces  are  separated,  osseous  union 
vriU  probably  not  occur.  This  accident  and  result  are  exemj)lified  in 
fracture  of  the  patella,  where  fibrous  or  ligamentous  union  is  the  great 
rule. 

The  diagnosis  of  fibrous  union  is  determined  from  continued  preter- 
natural mobility  at  the  seat  of  fracture  after  two  months  have  elapsed. 
Crepitus  is  not  to  be  depended  upon,  as  the  ends  of  the  fragments  may 
be  rounded  oif  by  absorption,  and  covered  over  with  infiammatory  newly 
formed  material,  or  at  times  with  cartilage. 

Treatment. — The  immediate  indication  is  to  correct  any  constitutional 
condition  which  may  be  present,  and  to  increase  general  nutrition. 
Syphilis,  or  any  recognized  dyscrasia,  must  be  specially  treated.     In  the 


324  '  A  TEXT-BOOK   ON  SURGERY. 

administration  of  tonics,  cod-liver  oU,  with  the  hypophosphites  of  lime 
and  soda,  should  play  an  important  part. 

It  is  of  importance  to  fix  the  broken  part  immovably  by  the  plaster- 
of-Paris  or  other  solid  dressing.  This  should  be  removed  after  four 
weeks,  in  order  to  allow  passive  motion  of  any  articulation  near  the  seat 
of  fracture,  and  necessarily  included  in  the  dressing.  After  the  first 
movement  of  the  joint  the  dressing  should  be  reapplied  and  the  passive 
motion  repeated  each  week.  Great  care  should  be  observed  to  prevent 
motion  at  the  seat  of  fracture.  If,  after  the  lapse  of  from  ten  to  fourteen 
weeks,  there  are  no  indications  of  union,  a  mild  inflammation  should  be 
induced  in  the  tissues  immediately  about  the  fracture.  This  may  be 
accomplished  by  forcibly  rubbing  the  ends  of  the  bones  together  (after 
an  anaesthetic  has  been  administered),  and  then  investing  the  member 
with  the  gypsum  dressing.  In  obstinate  cases  more  radical  measures 
may  need  to  be  adopted.  A  favorite  practice  is  to  ciit  down  iipon  the 
fracture,  dissect  away  any  new-formed  tissue,  and  saw  off  the  ends  of  the 
bones,  back  far  enough  to  reach  healthy  and  well-nourished  bone. 

It  may  sometimes  suffice  to  cause  inflammation  and  stimulate  bone- 
formation  by  puncturing  the  skin  with  an  awl  or  drill,  and  with  the  point 
of  this  instrument  scraping  the  ends  of  the  fragments. 

If  these  measures  fail,  the  bones  should  be  freshened  and  brought 
together  by  silver- wire  sutures,  as  advised  in  fracture  of  the  jaw,  or  by 
transfixion  with  movable  steel  drills,  in  the  same  manner  as  given  m 
excision  of  the  knee-joint. 


CHAPTER  XIII. 

STJEGERT   OF  THE  ARTICULATIONS. 

Dislocations. — A  dislocation  is  the  displacement  of  the  articular  sur- 
face of  one  bone  from  its  normal  relation  with  another.  Dislocations  are 
traumatiG,  patliological,  and  congenital.  They  are  also  partial  or  com- 
plete., simple,  complicated,  and  compound. 

Traumatic  dislocations  are  sudden,  and  result  from  violence  ;  patho- 
logical when,  from  disease  of  the  Joint,  the  bones  and  ligaments  are  more 
or  less  destroyed ;  congenital  when,  from  failure  of  development,  the 
normal  contiguity  of  the  articular  surfaces  can  not  be  maintained.  A 
dislocation  is  said  to  be  partial  when  any  portic)n  of  the  articular  sur- 
faces are  still  in  contact ;  complete  when  one  articular  end  overlaps  the 
other ;  simple  when  there  is  no  other  lesion  than  displacement  and  injury 
of  the  capsule ;  complicated  when  there  exists  with  the  dislocation  a 
fracture  into  the  joint ;  compound  when,  by  reason  of  a  wound,  the  air 
is  in  contact  with  the  dislocated  surfaces.  Again,  a  dislocation  may  be 
recent  or  ancient,  the  limit  of  the  former  variety  being  from  a  few  hours 
to  two  or  three  weeks.  A  primitive  luxation  is  one  in  which  the  dislo- 
cated surfaces  retain  the  same  position  as  at  the  time  of  the  accident, 
secondary  when  another  position  is  assumed. 

In  a  dislocation  the  capsule  may  be  ruptured,  or  simply  stretched 
without  a  solution  of  its  continuity.  When  great  violence  is  employed 
in  producing  it,  the  muscles,  tendons,  nerves,  vessels,  fascia,  and  skin 
about  the  joint  may  be  more  or  less  involved.  The  changes  which  follow 
are  practically  those  of  acute  synovitis,  arthritis,  or  peri-arthritis. 

Dislocations  occur  chieiiy  in  adult  life,  and  are  most  frequent  in 
those  joints  which  enjoy  the  greatest  freedom  of  motion,  and,  at  the 
same  time,  are  subjected  to  the  heaviest  strains.  The  condition  of  the 
individual,  the  tonicity  of  the  muscles,  and  the  strength  of  the  liga- 
ments, have  a  great  deal  to  do  with  the  frequency  of  dislocations.  All 
things  being  equal,  patients  with  poorly  developed  muscles  and  relaxed 
ligaments  are  more  prone  to  these  lesions  than  the  well  develo^sed  and 
vigorous. 

The  diagnosis  of  a  dislocation  rests  chiefly  upon  abnormal  immobility 
and  asymmetry.     Pain  is  usually  present. 

Special  Dislocations — Diferior  Jfaa^i'ZZa. —Displacement  of  the  con- 
dyles of  the  lower  jaw,  from  its  articulation  with  the  temporal  bone,  may 
occur  on  one  or  both  sides ;  usually  it  is  bilateral.     The  condyles  sMp 


326  A  TEXT-BOOK   ON   SURGERY. 

forward  and  are  engaged  partly  beneath  the  zygoma,  in  front  of  the  emi- 
nentia  articidaris,  and  partly  between  the  zygoma  and  the  temporal 
fossa.  Muscular  action  alone  may  produce  this  luxation,  or  it  may  be 
caused  by  external  violence. 

The  symptoms  are  great  pain,  difficult  deglutition,  and  indistinct 
articulation  (especially  of  the  labial  sounds).  The  lower  teeth  are  unusu- 
ally advanced,  the  mouth  is  widely  opened,  and  the  saliva  trickles  over 
the  lips. 

In  unilateral  luxation  the  chin  points  toward  the  sound  side,  and  the 
teeth  are  less  widely  separated. 

In  the  diagnosis  the  chief  point  of  differentiation  is  fracture  at  or  near 
the  condyle.  In  fracture  the  condyle  may  possibly  be  recognized  in  its 
normal  position  by  palpation  ;  immobility  is  not  marked ;  the  mouth  is 
not  opened  ;  crepitus  may  be  obtained. 

Reduction. — In  bilateral  displacement,  wrap  the  thumbs  Avith  sev- 
eral layers  of  bandage  or  cloth,  to  protect  them  from  being  bitten  when 
reduction  is  accomplished.  Place  one  thumb  along  the  inferior  molars 
of  each  side,  and  the  fingers  beneath  the  body  of  the  jaw  ;  press  down- 
ward and  backward  with  the  thumbs,  while  the  fingers  lift  the  chin 
upward. 

Or  place  a  thick  roll  of  leather,  piece  of  wood,  or  firm  cork,  between 
the  upper  and  lower  posterior  molars  of  each  side,  and  upon  these,  as  a 
fulcrum,  lift  the  chin  upward,  and  at  the  same  time  push  backward  in  the 
direction  of  the  socket. 

If  both  of  these  methods  fail,  they  should  be  repeated  under  ether. 
It  may  sometimes  be  advisable  to  attempt  the  reduction  of  one  side  by 
either  of  the  above  methods,  and  retain  it  in  position  while  reducing  the 
other. 

After  reduction  is  completed  put  on  a  head  and  chin  figure-of-8 
bandage,  and  allow  it  to  remain  for  a  week  (Fig.  24),  or  apply  Hamil- 
ton's head-stall  for  fracture  of  the  lower  Jaw  (Fig.  311).  In  several  in- 
stances, where  the  dislocation  has  become  ];)ermanent,  the  symptoms  have 
gradually  subsided,  and  a  fair  degree  of  motion  and  usefulness  acquired 
through  the  false  joint. 

Clamcle. — The  sternal  end  may  be  displaced  fonoard  on  the  manu- 
brium, upward  above  the  sternum,  hacTcioard  behind  the  manubrium. 
The  last  two  varieties  are  rare.  The  cause  of  the  first  form  is  usually 
force  applied  to  the  shoulder  with  the  arm  thrown  backward.  In  the 
case  of  a  boy  fifteen  years  old,  treated  by  myself,  the  displacement  was 
caused  by  a  comrade  catching  him  by  both  shoulders,  placing  his  knee 
in  the  middle  of  the  back,  between  the  shoulder-blades,  and  violently 
pulling  the  shoulders  back. 

The  diagnosis  is  not  difficult,  the  reduction  easy,  but  the  maintenance 
of  the  bone  in  position  difficult.  A  compress,  covered  with  adhesive 
I)laster  to  prevent  slipping,  placed  upon  the  bone  after  reduction,  and 
firmly  held  in  place  by  a  roller,  is  a  proper  method  of  treatment.  The 
arm  should  be  fixed  with  Sayre's  apparatus  for  fractured  clavicle,  in 
order  to  prevent  a  repetition  of  the  luxation. 


DISLOCATIONS. 


327 


The  oiiter  end  of  the  clavicle  may  be  displaced  above  or  below  the 
acromion  ijrocess,  and  above  or  in  front  of  the  coracoid  process.  Dis- 
placements under  the  acromion  and  in  front  of  the  coracoid  are  very 
rare. 

The  symptoms  are  very  distinct,  and  the  reduction  not  surrounded 
vfith  great  difficulty.  When  replaced,  however,  the  bone  is  with  diffi- 
culty maintained  in  position.  By  drawing  firmly  outward  upon  the 
shoulder  of  the  affected  side,  and  j)ressing  the  clavicle  downward  into 
position,  redaction  will  be  successfully  accomplished.  Place  a  firm  com- 
press over  the  end  of  the  bone,  bend  the  forearm  at  right  angles  to  the 
arm,  and  carry  one  or  two  strong  strips  ^f  adhesive  plaster  over  the  com- 
press, behind  the  shoulder,  along  the  arm  to  the  olecranon,  and  again  by 
the  front  over  the  compress.  Re-enforce  this  by  a  bandage,  and  place  the 
arm  in  a  sling.  If  luxation  recurs,  tighten  the  adhesive  strips,  and  place 
the  arm  in  a  Velpeau's  bandage.  To  apply  this  bandage,  place  the  hand 
of  the  affected  side  almost  uj)on  the  ojipo- 
site  shoulder,  fixing  a  wad  of  cotton  be- 
neath each  axilla.  Lay  the  end  of  a  roller 
on  the  shoulder-blade  of  the  sound  side, 
and  carry  the  bandage  over  the  acromial 
end  of  the  clavicle  of  the  injured  side,  and 
the  fi-ont  of  the  ami  for  a  short  distance, 
passing  obliquely  to  the  under  surface  at 
the  elbow,  and  around  beneath  the  well  ax- 
illa to  the  point  of  starting.  Repeat  this 
to  secure  the  roller,  and  then  carry  the 
bandage  horizontally  around  the  chest  and 
over  the  tip  of  the  elbow.  The  oblique  and 
horizontal  turns  are  alternated  until  the 
shoulder  and  arm  are  completely  enveloped 
(Fig.  352). 

Humerus,  at  the  Shoulder. — Disloca- 
tion at  the  shoulder- joint  is  by  far  the  most 
frequent.  It  may  take  place  in  three  direc- 
tions— iaclcward,  under  the  spine  of  the 
scapula  {subacromial  and  subspinous)  ; 
do'wnward,  below  the  glenoid  cavity  {subglenoid) ;  and  forward,  be- 
neath the  coracoid  or  clavicle  {subcoracoid  or  suhclamcular). 

The  first  variety  is  of  rare  occurrence.  The  subacromial  dislocation  is 
only  a  partial  displacement,  and  becomes  complete  when  the  head  of  the 
bone  passes  well  beneath  the  spine  of  the  scapula  (Fig.  357).  The  sub- 
glenoid is  more  frequent,  but  not  so  common  as  the  subcoracoid.  Dis- 
placement forward  under  the  clavicle  is  rare.  On  account  of  the  coraco- 
acromial  ligament,  and  the  additional  protection  afforded  to  the  joint 
above  by  the  acromion  process,  dislocation  directly  upward  can  scarcely 
occur. 

Subcoracoid  and  Suhclamcular  Dislocation. — In  the  more  frequent 
variety  of  luxation — the  subcoracoid — the  capsule  is  ruptured  along  the 


Fig.  352. — Velpeau's  bandage.     (After 
Stimson.) 


328 


A  TEXT-BOOK   ON   SURGERY. 


lower  and  inner  portion,  extending  to  the  insertion  of  the  subscapularis 
muscle.  It  is  caused  by  violence  applied  directly  to  the  shoulder  from 
without  inward  and  forward,  or  to  the  elbow  or  hand  when  the  extremity 
is  extended.  The  head  of  the  humerus  rests  upon  and  in  front  of  the 
inner  rim  of  the  glenoid  cavity  and  just  underneath  and  in  contact  with 
the  coracoid  process  (Fig.  359).  The  acromion  j)rocess  is  unusually 
prominent,  a  depression  is  felt  beneath  it,  while  the  head  of  the  bone  is 
seen  and  felt  in  an  abnormal  position  beneath  the  coracoid.  The  hu- 
merus stands  stiffly  away  from  the  chest  at  an  angle  varying  from  twenty 
to  thirty  degrees.  The  circumference  of  this  shoulder,  measured  over  the 
acromion  and  through  the  axilla,  is  greater  by  at  least  one  inch  than  on 
the  opposite  side  (Callaway).  If  the  hand  of  the  affected  side  is  placed 
upon  the  sound  shoulder,  the  elbow  can  not  be  carried  down  to  the  chest- 
wall  (Dugas). 

According  to  Kocher — whose  researches  are  based  on  anatomical  as 
well  as  clinical  demonstrations,  the  obstacle  to  reduction  is  tension  of 
the  capsule,  especially  of  the  coraco-humeral  ligament,  with  conse- 
quent closure  of  the  rent  through  which  the  head  of  the  humerus  has 
escaped.  If  this  displacement  exists,  by  carrying  the  humerus  directly 
down  until  the  arm  touches  the  side  of  the  chest-wall,  rotating  it  out- 
ward and  then  carrying  the  elbow  in  front  of  the  chest  to  the  middle  line, 
the  capsule  is  relaxed  and  the  rent  is  opened.  It  only  remains  to  rotate 
the  humerus  slightly  toward  the  body,  when  the  head  slips  through  the 
opening  back  into  its  normal  position. 

Dr.  Charles  A.  Powers,  of  New  York,  has  shown  that  the  recumbent 
posture  is  preferable  to  the  sitting  position  which  was  original  with 
Kocher.  The  steps  of  this  method  are  well  shown  in  the  accompanying 
cuts  taken  from  his  article.* 


Fig.  353.— I-ir  t  \1     im  i  I      J  li       I  I  I     i    1  I     the  body  and  drawn  downward.     (The  arm  and 

wiibt  should  II  tiiml>  ^iisiul    I    sU  \\n  in  the  figure)    (After  Dr.  C.  A.  Powers.) 

*  "  Medical  Kecord,"  March  30,  1889. 


DISLOCATIONS. 


329 


MetJiod. — Place  the  isatient  on  the  back,  upon  a  hard  table  or  the 
floor,  with  an  assistant  holding  the  shoulder  of  the  sound  side  firmly 
down.     The  operator  grasps  the  member  of  the  inju]-ed  side  at  the  wrist 


Fig.  354. — Secoud   Movement.      The  arm  is  rotated  out  until   tirm   resistanoe   is   met.      (Praotioally  until 
the  long  axis  of  the  forearm  points  directly  outward.)     (After  Dr.  C.  A.  Powers.) 

and  elbow  and  brings  the  humerus  well  against  the  wall  of  the  chest 
(Fig.  353).  Outward  rotation  is  made  until  the  long  axis  of  the  forearm 
points  directly  outward  (Fig.  354).  when  the  elbow  is  brought  along 
the  front  of  the  chest  to  the  median  line  (Fig.  355)  and  the  hand  of 


Fig.  355. — Third  Movement.    With  the  external  rotation  of  the  arm  still  maintained,  the  elbow  is  car- 
ried forward  and  upward  on  the  chest.     (After  Dr.  C.  A.  Powers.) 

the  affected  side  placed  on  the  sound  shoulder  (Fig.  356").  If  this 
fail,  repeat  the  procedure.  An  anaesthetic  is  not  usually  required,  but 
should  be  given  if,  after  two  or  three  efforts,  reduction  is  not  accom- 


330 


A  TEXT-BOOK  ON  SURGERY. 


plished.     The  method  of  using  the  foot  in  the  axilla,  as  given  for  sub- 
glenoid luxation,  may  also  be  tried. 


Fig.  356. — Fourth  Movemeut.     The  hand  is  iilaruJ  on  tliu  souuj  sliuuldcr.     (After  Dr.  C.  A.  Powers.) 

The  subclavicular  variety  of  this  forward  dislocation  is  only  an  exag- 
geration of  the  subcoracoid,  in  which  the  head  of  the  bone  slips  under- 
neath and  internal  to  the  coracoid,  and  rests  against  the  serratus  mag- 
nus  and  behind  the  pectoralis  minor,  below  the  clavicle  (Fig.  360).  The 
causes  are  the  same,  and  the  symptoms  differ  in  little  else  than  the  pres- 
ence of  the  head  of  the  humerus  nearer  to  the  clavicle.  The  arm  stands 
slightly  out  from  the  body,  and  the  elbow  is  tilted  backward.  The  ten- 
sion on  the  posterior  scapular  muscles  is  greater,  and  rupture  of  their 
attachments  often  occurs,  while  the  anterior  insertion  of  the  subscapii- 
laris  may  be  dissected  up.  Pressure  on  the  axillary  vessels  and  nerves 
is  more  marked  in  this  luxation.  Reduction  may  be  effected  by  the 
means  just  described.  " 

Subglenoid  Dislocation.— Ito.  the  subglenoid  luxation  the  capsiile  is 
stretched  or  torn  along  its  lower  surface,  and  the  head  of  the  humerus 
rests  upon  the  margin  of  the  glenoid  cavity  in  a  partial  dislocation,  or,  if 


Fig.  357. 
Subacromial  and  sub- 
spinous.   (Bryant.) 


Fig.  360. 

Subclavicular. 

(Bryant.) 


DISLOCATIONS. 


331 


the  capsxile  is  torn,  it  (iisiially)  slips  in  front  of  the  long  tendon  of  the 
triceps,  and  is  lodged  ujjon  the  axillary  border  of  the  scapula,  immedi- 
ately below  the  articular  surface  (Fig.  358).  The  supra-spinatus  muscle 
is  severely  stretched,  and  either  suffers  rupture  of  its  tendon  or  sub- 
stance, or,  rather  than  yield,  it  may  tear  off  a  rim  of  the  upper  facet  of 
the  greater  tuberosity.  The  long  head  of  the  biceps  and  the  coraco- 
brachialis  are  also  subjected  to  great  strain  or  rapture,  while  the  tension 
of  the  deltoid  holds  the  arm  in  a  position  with  the  elbow  slightly  tilted 
from  the  side  of  the  body. 

Among  the  less  frequent  complications  of  this  lesion  may  be  men- 
tioned pressure  upon  the  circumflex  and  axillary  nerves,  and  injury  or 
rupture  of  the  great  vessels. 

The  cause  of  this  dislocation  is  violence  applied  to  the  shoulder  in  a 
direction  from  above  downward,  or  indirectly  to  the  hand,  forearm,  or 
elbow,  with  the  humerus  raised  at  or  beyond  an  angle  of  90°  to  the  axis 
of  the  trunk. 

The  diagnosis  of  a  subglenoid  luxation  will  depend  upon  the  follow- 
ing symptoms :  The  acromion  process  is  unusually  prominent,  the  head 
of  the  bone  is  not  in  its  normal  relation  to  this  process,  and  may  be  felt 
low  down  in  the  axillary  space.  There  is  a  depression  in  the  anterior 
axillary  fold  in  these  subjects.  The  arm 
is  fixed  in  such  a  manner  that  the  elbow 
is  directed  outward  from  the  side  of 
the  body  (Fig.  361).  As  in  all  the  shoul- 
der dislocations,  the  arm  is  so  held  that, 
if  the  hand  of  the  injured  side  be  placed 
on  the  opposite  shoulder,  the  elbow  can 
not  be  made  to  drop  down  xipon  the  wall 
of  the  thorax.  This,  the  test  of  Dugas, 
is  important  in  dilferentiation  from  fract- 
ure in  which  there  is  such  a  considerable 
degree  of  motion  j)ossible  that  the  arm 
can  be  broxight  well  down  upon  the  chest. 
There  is  always  preternatural  immobility  in  a  dislocation.  Another 
excellent  method  of  differentiation  is  that  of  Callaway,  based  upon  the 
fact  that  the  circumference,  measured  over  the  acromial  end  of  the 
clavicle  and  the  acromion,  and  through  the  axilla,  is  in  a  dislocation 
much  increased  over  the  normal,  or  over  that  present  in  fracture  at  the 
neck.     Crepitus,  when  obtained,  will  determine  a  fracture. 

Reduction — First  Method. — Place  the  patient  iipon  a  table,  bed,  or 
upon  the  floor.  For  the  left  shoulder  the  operator  removes  the  shoe 
from  the  left  foot  and  places  it  in  the  axilla,  against  the  thorax.  He  now 
seizes  the  arm  and  forearm  of  the  patient,  carries  it  out  at  a  right  angle 
to  the  axis  of  the  patient's  spine,  and  makes  powerful  traction  in  the 
direction  of  the  glenoid  cavity.  While  this  is  being  effected  the  arm  is 
brought  inward,  parallel  with  and  against  the  side  of  the  body  (Fig. 
362).  The  foot  not  only  serves  to  effect  counter-extension,  bttt  is  also 
used  as  a  fulcrum  for  lifting  the  head  of  the  bone  over  the  edge  of  the 


Fig.  361.— Subglenoid.     (Bryant.) 


332 


A  TEXT-BOOK   ON   SURGERY. 


glenoid  facet  into  the  articular  cavity  of  this  process.     If  this  can  not 
be  accomplished  without  ether,  after  one  or  two  trials  the  aneesthetic 


Fig.  3G2.— (Ericlisen.) 

should  be  given.  After  reduction  a  shoulder -cap  of  book-binder's 
board,  leather,  or  gutta-percha  should  be  applied,  and  worn  for  at  least 
one  week. 

Second  Method. — Fix  the  scapula  by  placing  a  folded  sheet  or  long 
cloth  around  the  body,  so  that  the  upper  margin  of  the  cloth  will  toucli 
the  axillary  folds.     The  ends  are  intrusted  to  an 
assistant,  who,  standing  on  the  sound  side,  makes  -.A-':--', 

counter-extension.     The  surgeon  now  takes  hold  of  \    ,,A    j 

the  arm  about  its  middle  with  one  hand,  and  near  "^-j     ""'.. 

the  elbow  with  the  other,  and  carries  it  slowly  and  \1  V 

steadily  away  from  the  body,  and  in  the  direction  of  ]     \ 

least  resistance.  When 
it  is  at  a  right  angle  to 
the  axis  of  the  body, 
strong  traction  is  made, 
with  slight  axial  rota- 
tion. If  the  manoeuvre 
is  still  unsuccessful,  car- 
ry the  arm  higher,  until 
extension  is  made  in  the 
line  of  the  axillary  border  of  the  scapula 
(Fig.  363). 

Third  Method.— Place  the  patient  in  a 
chair,  so  that,  with  the  foot  of  the  opera- 
tor on  the  edge  of  the  seat,  his  knee  will 
come  snugly  into  the  axilla.  Place  one 
hand  upon  the  shoulder  to  steady  it,  while 
the  other  seizes  the  arm  near  the  elbow. 
FiQ.  363  a.— (After  Hamilton.)  With  the  kuee  as  a  fulcrum,  use  the  hu- 


FiG.  3C3.— (Brjaut.) 


DISLOCATIOXS.  333 

merns  as  a  lever,  wliicti,  Ijeing  depressed,  carries  the  head  of  the  bone  into 
position  (Fig.  363  a).  Extension  from  the  forearm,  and  counter-exten- 
sion through  the  medium  of  the  opposite  arm,  may  also  be  employed. 

The  subacromial  and  subspinous  dislocations  are  reducible  by  exten- 
sion and  counter-extension  in  the  line  of  displacement.  Counter-exten- 
sion may  be  made  by  an  assistant  holding  the  arm  of  the  sound  side,  or 
by  the  folded  sheet  (already  described)  api^lied  just  in  the  axilla.  The 
operator  makes  extension  from  the  arm  and  forearm,  imparting  to  the 
humerus  a  slight  axial  rotation. 

General  Considerations. — Recent  dislocations  at  the  shoulder  may 
not  always  be  reduced,  and  some  which  are  readily  replaced  are  with 
difficulty  held  in  position.  E,ui)ture  of  any  muscle,  or  group  of  muscles, 
renders  the  luxation  subject  to  recun^ence,  since  there  is  no  antagonism 
to  the  remaining  muscles.  Even  when  reposition  is  effected  and  main- 
tained, the  function  of  the  joint  maybe  permanently  impaired  on  accoimt 
of  injury  to  the  surrounding  structures.  Injury  of  the  cu-cumflex  nerve 
has  been  followed  by  atrophy  of  the  deltoid  and  teres  minor,  while  trau- 
matism of  the  great  cords  of  the  axillary  plexus  and  injury  of  the  vessels 
have  led  to  impaii-ment  or  loss  of  function  in  the  extremity.  Ligature  of 
the  subclavian  artery  and  amputation  have  been  necessitated  after  dislo- 
cation of  the  shoulder- joint. 

These  injuiies  may  occur  at  the  time  of  the  displacement,  or  they  may 
be  produced  by  a  lack  of  skill  or  the  employment  of  too  great  force  in 
the  efforts  at  reduction. 

After  one  or  two  days  from  the  date  of  a  luxation  at  the  shoulder  (as 
elsewhere)  the  difficulties  of  reduction  increase,  and  are  in  general  pro- 
portionate to  the  length  of  time  which  has  elapsed  since  the  accident. 
At  the  expiration  of  the  first  week  inflammatory  adhesions  occur,  and 
the  cavity  of  the  joint  is  in  part  filled  with  the  products  of  inflammation. 
In  rare  cases  reduction  has  been  accomplished  at  the  end  of  three,  six, 
and  twelve  months. 

The  propriety  of  attempting  reduction  in  ancient  shoulder  luxations 
will  depend  upon  the  individual  case.  It  will  frequently  occur  that,  in 
the  new  position,  attachments  are  formed,  with  ligaments,  cartilage,  and 
synovial  membrane,  with  fair,  yet  limited,  motion  in  the  false  joint, 
which,  together  ^^ith  the  free  mobility  of  the  scapula  upon  the  thorax, 
gives  a  useful  degree  of  motion  to  the  arm.  Under  such  conditions  any 
attempt  at  reposition  is  unnecessary. 

In  well-selected  cases,  where  an  ancient  dislocation  can  not  be  reduced 
by  any  other  means  consistent  mth  safety  to  the  tissues  about  the  joint, 
and  where  motion  is  so  limited  that  the  usefulness  of  the  ami  is  seriously 
impaired,  direct  incision,  under  strict  antiseptic  precautions,  may  be 
employed,  and  reduction  thus  effected,  with  or  without  excision  of  the 
head  of  the  humerus.  After  the  head  of  the  bone  is  returned  to  its  nor- 
mal position,  drainage  should  be  secured  through  the  rent  or  incision  in 
the  capsule.  A  Keubefs  bone-drain,  or  a  soft  rubber  tube,  may  be  em- 
ployed, and  should  be  so  placed  that  it  will  lead  downward  fi'om  the  most 
dependent  portion  of  the  capsule. 


334  A  TEXT-BOOK   ON   SURGERY. 

Dislocations  at  the  Elbow-Joint. — The  upper  end  of  the  radius 
may  be  displaced  forward  on  to  the  anterior  surface  of  the  humerus, 
near  the  coronoid  fossa,  or  backward  upon  the  olecranon  process.  The 
anterior  displacement  is  met  with  somewhat  more  frequently  than  the 
posterior. 

In  the  displacement  forward  the  orbicular  and  a  portion  of  the  exter- 
nal lateral  and  anterior  ligaments  are  ruptured  ;  in  the  ojDposite  luxation 
only  the  first  two  are  lacerated. 

The  forward  displacement  is  caused  by  direct  violence  applied  to  the 
jjosterior  aspect  of  the  upper  end  of  the  radius,  or  by  falling  upon  the 
palm  of  the  hand  while  the  forearm  is  completely  extended,  the  full  force 
of  the  contraction  of  the  biceps  being  thus  added  to  the  force  transmitted 
along  the  shaft  of  the  bone. 

Symptoms. — Careful  palpation  will  reveal  the  abnormal  presence  of 
the  head  of  the  radius  near  the  center  of  the  humerus,  while  pressure 
along  the  outer  condyle  will  demonstrate  its  absence  from  its  natural 
position.     The  forearm  is  semiflexed  and  slightly  pronated. 

Treatment. — Flex  the  arm  and  push  the  head  of  the  bone  forcibly 
downward  in  the  direction  of  the  articulation.  When  reduction  is  ac- 
complished, place  a  compress  over  the  upper  end  of  the  bone  and  the 
external  condyle,  and  bind  it  firmly  in  position.  The  arm  should  be 
snugly  bandaged,  and  carried  in  a  sling  for  several  weeks. 

The  backward  dislocation  is  recognized  by  the  presence  of  the  head  of 
the  bone  in  an  abnormal  position  near  the  olecranon,  behind  the  external 
condyle. 

Treatment.— While  an  assistant  makes  strong  extension  and  counter- 
extension  from  the  hand  and  arm,  the  operator  makes  direct  pressure 
upon  the  head  of  the  bone,  forcing  it  in  the  direction  of  the  articulation. 
As  the  displacement  is  being  corrected  the  assistant  should  carry  the 
forearm  in  a  position  of  supination.  The  after-treatment  consists  of  a 
compress  and  bandage,  worn  for  several  weeks. 

The  pr or/ ?iosis  of  this  injury  is  generally  not  favorable,  since  it  is  very 
apt  to  recur  after  reduction,  and  may  become  permanent.  A  fair  degree 
of  usefulness  is  maintained,  however,  in  many  cases  of  chronic  luxation 
of  this  end  of  the  radius. 

Complete  forward  dislocation  of  the  nlna  alone,  at  the  elbow,  can  not 
occur  without  fracture  of  the  radius  or  extensive  laceration  of  the  radio- 
ulnar ligaments. 

Subluxation  of  the  Head  of  the  Radius.— This,  lesion  is  met  with 
usually  in  children  from  nine  years  old  and  under,  and  is  much  more 
common  than  complete  dislocation  at  this  joint.  It  is  caused  by  sudden 
traction  on  the  hand  or  forearm  in  lifting  a  child  by  a  single  arm  or  in 
saving  it  in  the  act  of  falling. 

The  symptoms  are  loss  of  function,  the  arm  often  hanging  as  if  it 
could  not  be  moved.  Motion  at  the  wrist  may  be,  however,  free.  Press- 
ure over  the  head  of  the  radius  causes  sharp  pain.  Passive  flexion  at 
the  elbow  is  permitted  to  about  60°,  when  resistance  may  be  met  with. 
Complete  extension  is  also  painful.     With  the  forearm  flexed  at  right 


DISLOCATIONS.  335 

angles  to  the  arm,  pronation  is  possible,  but  is  slightly  resisted,  while 
supination  causes  great  pain.  If,  however,  this  movement  is  carried  to 
the  extreme,  a  distinct  click  may  be  heard  and  felt  at  the  head  of  the 
radius,  with  which  the  pain  suddenly  ceases  and  free  motion  is  re- 
established (W.  W.  Van  Arsdale).*  Reposition  is  thus  effected.  With 
the  patient  sitting  or  standing  in  front  of  the  operator,  he  grasps  the  arm 
just  above  the  elbow  with  one  hand,  while  with  the  other  the  forearm 
is  seized  near  the  wrist.  The  forearm  is  now  flexed  to  an  angle  of  ninety 
degrees  with  the  arm,  and  steadily  rotated  into  a  position  of  extreme 
sujjination.  As  above  stated,  the  reduction  is  accompanied  by  a  per- 
ceptible slip  or  click.  A  splint  should  be  applied  to  hold  the  arm  quiet 
in  the  right-angle  position  for  four  or  five  days. 

The  pathological  conditions  of  this  lesion  are  not  thoroughly  un- 
derstood. Since  it  is  caused  by  puUing  upon  the  radius,  the  cup- 
shaped  articular  facet  of  the  head  of  this  bone  is  evidently  abnonnally 
separated  from  the  humerus.  One  theory  is  that  the  soft  parts  are  in- 
terposed either  by  muscular  action  or  by  atmospheiic  pressure,  while 
another  holds  that  the  edge  of  the  head  of  the  radius  is  slightly  locked 
on  the  humerus,  a  complete  dislocation  being  prevented  by  the  integrity 
of  the  capsule. 

Dislocation  of  hoth  radius  and  ulna  at  the  elbow  may  take  place  in 
all  directions. 

The  dislocation  backward  may  be  produced  by  falling  upon  the  hand 
with  the  forearm  almost  extended  ;  by  a  blow  upon  the  anterior  aspect 
of  the  forearm,  near  the  elbow,  a  blow  upon  the  posterior  snrface  of  the 
humerus,  in  its  lower  portion,  or  force  applied  at  the  same  time,  in  oppo- 
site directions,  uj)on  these  surfaces.  The  coronoid  process  will  be  found 
lodged  in  the  olecranon  fossa,  the  upper  end  of  the  radius  resting  on  the 
posterior  aspect  of  the  external  condyle. 

The  anterior  ligament  and  the  anterior  fasciculi  of  the  external  and  in-  ■ 
ternal  lateral  ligaments  are  torn  loose,  and  in  extreme  cases  the  orbicular 
ligament  may  give  way,  although  the  yielding  of  the  external  ligament 
usually  saves  the  circular  ligament  from  being  torn.  The  tendon  of  the 
brachialis  anticus  is  stretched  or  is  broken  loose  from  the  coronoid  pro- 
cess. Pressure  upon  the  brachial  artery  may  be  so  great  that  pulsation 
at  the  wrist  is  diminished  or  absent,  while  in  extreme  cases  the  median, 
ulnar,  or  musculo-spiral  nerves  may  be  injured. 

The  usual  position  of  the  forearm  is  one  of  almost  comj)lete  extension, 
with  pronation.  Measurement  from  the  inner  condyle  to  the  styloid 
process  of  the  ulna  will  demonstrate  shortening.  Muscular  rigidity  is 
marked,  and  motion  of  the  displaced  bones  difiicult  and  painful.  From 
these  symptoms  the  diagnosis  can  be  readily  made.  If  swelling  has 
ensued,  and  the  tumefaction  is  great,  it  is  not  always  easy  or  jDossible  to 
recognize  the  character  of  the  injury.  Under  such  conditions  it  is  wise 
to  reduce  the  swelling  by  rest  and  local  apjjlication  for  a  few  days,  until 
the  exact  character  of  the  luxation  may  be  determined. 

*  "Annals  of  Surgery,"  June,  1889. 


336 


A  TEXT-BOOK   ON  SURGERY. 


Fm.  364.— (Eriehsen.) 


Treatment — Reduction — Method  ofAstley  Cooper. — Witli  the  patient 
seated  in  a  chair,  the  operator  places  his  foot  on  the  seat  so  that  the 

anterior  aspect  of  the  patient's  forearm  will 
be  brought  in  contact  with  the  anterior  sur- 
face of  the  surgeon's  knee.  The  forearm 
should  now  be  grasped  near  the  wrist  and 
forced  flexion  made,  using  the  knee  as  a 
fulcrum,  and  at  the  same  time  as  a  point  of 
resistance  to  the  extension  made  by  pull- 
ing upon  the  forearm  (Fig.  364). 

Flexion  unlocks  the  coronoid  process 
from  the  olecranon  fossa,  and  extension 
carries  both  bones  forward  into  position. 
Unless  the  ojierator  is  positive  that  perfect 
reduction  has  been  accomplished,  the  joint 
should  be  freely  flexed  and  extended  to 
test  its  working  capacity.  Care  must  be 
taken  to  hold  the  muscles  in  check  while 
this  manipulation  is  going  on,  for  fear  the 
bones  may  again  slip  out  of  place.  Band- 
age the  arm  and  forearm,  and  apply  a 
splint,  which  should  be  worn  for  a  week 
or  two.  When  an  ansesthetic  is  used  the 
recumbent  posture  should  be  maintained.  The  bare  foot  may  be  utilized 
instead  of  the  knee. 

A  cloth  or  sheet  folded  around  the  arm,  just  above  the  elbow,  may  be 
used  for  counter-extension. 

Liston  advised  strong  extension  from  the  forearm,  and  counter-exten- 
sion from  the  shoulder,  with  the  arm  and  forearm  held  straight. 

Dislocation  of  the  radius  and  ulna  forward,  without  fracture  of  the 
olecranon,  is  of  rare  occurrence,  and  is  always  the  result  of  great  violence. 
Rupture  of  the  posterior  and  lateral  ligaments  occurs,  and  the  triceps 
tendon  is  torn  or  greatly  stretched,  while  the  brachialis  anticus  and  biceps 
are  relaxed.  The  posterior  portion  of  the  olecranon  rests  upon  the  ante- 
rior articular  aspect  of  the  humerus,  or  may  slip  into  the  coronoid  fossa. 
The  forearm  is  bent  at  an  angle  varying  from  90°  to  120°  to  the  anterior 
surface  of  the  humerus,  and  is  well  supinated.  Motion  is  painful  and 
limited.  The  character  of  the  injury  may  be  determined  by  the  absence 
of  the  olecranon  projection,  the  smooth,  broad,  posterior  surface  of  the 
lower  end  of  the  humerus  being  readily  appreciated. 

Treatment. — An  anaesthetic  is  iisually  required.  With  the  forearm 
held  at  about  a  right  angle  to  the  ami,  make  extension  from  the  wrist, 
and  counter-extension  from  the  lower  anterior  surface  of  the  humerus,  in 
order  to  disengage  the  olecranon  process  from  the  coronoid  fossa,  and, 
when  this  is  effected,  make  direct  pressure  downward  upon  the  anterior 
aspect  of  the  forearm,  near  the  elbow.  After  the  bones  slip  seemingly 
into  position,  careful  examination  should  be  made  to  see  that  the  radius 
is  in  its  proper  relation  to  the  external  condyle,  for  the  ridge  between  the 


DISLOCATIONS.  337 

two  sigmoid  cavities  of  the  nlna  may  lodge  in  the  groove  between  the 
trochlear  surface  and  the  articular  surface  for  the  head  of  the  radius. 

In  the  outward  lateral  dislocation  the  luxation  is  iisually  partial. 
The  cause  is  direct  violence  applied  to  the  inner  aspect  of  the  forearm, 
near  the  joint,  or  to  the  outer  aspect  of  the  humerus,  low  down,  or  to 
force  aj^plied  simultaneously,  in  opposite  directions,  upon  these  two 
surfaces. 

The  diagnosis  will  rest  chiefly  upon  the  increased  prominence  of  the 
inner  condyle,  and  the  difficulty  of  recognizing  the  outer  condyle  by  pal- 
pation. The  angle  at  the  elbow  is  about  120^,  motion  is  wanting,  and  the 
hand  is  pronated.  Reduction  is  best  effected  by  strong  extension  from 
the  forearm,  counter-extension  from  the  humerus,  and  direct  lateral 
pressure  in  the  direction  of  the  displacement. 

Inward  dislocation  is  always  incomplete  (Hamilton).  The  causes  are 
direct  violence  in  the  opposite  direction  to  that  given  for  the  luxation 
outward.  The  internal  condyle  will  be  less  prominent,  the  external  more 
prominent,  the  olecranon  will  be  seen  crowded  over  to  the  inner  aspect 
of  the  Joint,  while  the  head  of  the  radius  rests  near  the  middle  of  the 
articular  surface  of  the  humerus.  The  position  of  the  forearm  is  that  of 
flexion.  Reduction  is  difficult,  and  should  be  effected  in  ether  narcosis. 
Extension  and  counter-extension  should  be  made  in  the  flexed  position, 
and  the  arm  gradually  brought  out  straight,  while  at  the  same  time  direct 
pressure  is  made,  in  proper  and  opposite  directions,  upon  the  humerus 
and  forearm,  near  the  joint. 

Dislocation  of  both  bones  backward  is  the  most  frequent  form  of  dis- 
placement at  the  elbow.  Incomplete  external  and  incomplete  internal 
luxation  are  next  in  order  of  frequency,  while  the  forward  dislocation  is 
most  infrequent. 

In  the  posterior  variety  the  direction  of  the  force  may  be  such  that  a 
deviation  to  one  or  the  other  side  may  occur.  The  treatment  is  practi- 
cally the  same.  Direct  lateral  pressure  in  the  line  of  the  normal  position 
of  the  bone  may  be  required  in  addition  to  the  mechanism  of  reduction 
above  given.  Partial  anchylosis  is  not  infrequent  after  these  lesions. 
Passive  motion  should  be  begun  within  two  weeks  after  the  injury,  and 
repeated  daily  if  no  acute  inflammation  is  produced. 

Wrist-Joint. — Dislocations  at  the  carpo-radial  joint  are  very  rare. 
Only  a  few  instances  of  complete  backward  or  forward  luxation  of  the 
carpus  are  on  record.  Lateral  dislocations  are  considered  impossible 
without  fracture  of  the  styloid  process  of  the  radius  or  ulna.  The  two 
principal  displacements  occur  with  about  equal  frequency.  In  the  hacJc- 
ward  variety  the  anterior  aspect  of  the  carpus  rests  upon  the  dorsal  rim 
of  the  cancellous  expansion  of  the  radius,  the  reverse  being  true  in  the 
dislocation  fonoard.  The  anterior  and  j)osterior  ligaments  are  partially 
or  completely  ruptured,  and  the  annular  ligament,  which  binds  the  ten- 
dons down,  may  be  torn  and  the  tendons  displaced. 

The  cause  of  the  backward  displacement  is  a  faU  on  the  back  of 
the  hand,  or  a  blow  upon  the  dorstim  of  the  radius,  just  above  the 
wrist,  while  the  hand  is  in  extreme  flexion.  Violence  of  a  similar 
22 


338 


A  TEXT-BOOK   ON   SURGERY. 


character,  applied  in  the  opposite  direction,  will  produce  the  forioard 
luxation. 

The  diagnosis  must  be  made  between  Colles's  fracture  and  disloca- 
tion. In  dislocation  the  deformity  from  the  over-riding  carpus  is  much 
greater  than  after  fracture.  In  Colles's  fracture  the  swelling  on  the 
dorsum  of  the  wrist  is  smooth  and  rounded.  When  impaction  has  not 
occurred  crepitus  may  be  obtained. 

Reduction  is  effected  by  extension  and  counter-extension  from  the 
forearm  and  hand,  to  which  direct  pressure  in  the  line  of  displacement 
should  be  added. 

Dislocation  of  the  metacarpal  bones,  at  their  carpal  extremities,  is 
rare.  -  Luxation  of  the  metacarpal  bone  of  the  thumb  is  most  frequently 
met  with.  The  carpal  end  of  this  bone  may  be  displaced  partially  or 
completely,  in  a  forward  or  bacTcward  direction.  'When  the  end  of  the 
bone  rests  upon  the  dorsum  of  the  trapezius  it  can  be  easily  recognized. 

Extension  and  counter-extension,  with  direct  pressure,  is  usually  suffi- 
cient to  accomplish  reposition.  A  clove-hitch  or  snare  may  be  thrown 
around  the  thumb  to  insure  extension.  Reduction  is  at  times  difficult, 
and  the  history  of  this  accident  is  not  without  a  record  of  failure  both  as 
to  replacement  and  retention  when  replaced. 

In  the  displacement  forward,  on  account  of  the  thickness  of  the  soft 
parts,  the  end  of  the  bone  can  not  be  easily  recognized.  An  unusual 
depression  may  be  observed  on  the  radial  and  dorsal  aspects  of  the  wrist, 
just  in  front  of  the  os  trapezium. 

Strong  extension  with  counter-extension  is  necessary,  and  to  this 
should  be  added  direct  pressure,  applied  near  the  end  of  the  dis]3laced 
bone. 

Luxation  of  the  remaining  metacarpal  bones  occurs  rarely,  and,  when 
met  with,  the  displacement  is  usually  partial,  and  toward  the  dorsum  of 
the  carpus. 

The  phalanges  may  be  dislocated  either  hacTcward  or  forward  at  the 
metacarpal  articulations,  or  at  the  interphalangeal  joints.     The  character 


Fig.  365.— (After  Hamilton.) 


of  the  lesion  is  easily  recognized,  and  the  reduction,  as  a  rule,  is  not  diffi- 
cult. Extension  with  a  clove-hitch,  or  with  the  apparatus  shown  in 
Fig.  365,  will  effect  reduction.  In  some  instances  operative  interference 
is  demanded  when  reposition  by  extension  and  pressure  can  not  be 
effected.  Careful  asepsis  should  be  observed.  On  opening  into  the 
joint,  the  resisting  ligaments  should  be  snipped  with  a  sharp  bistoury, 
when  the  displacement  may  be  easily  corrected. 

Hip-Joint. — WhUe  the  head  of  the  femur  may  be  displaced  from  the 
cotyloid  cavity  in  any  direction,  it  is  customary  to  consider ybwr  distinct 


DISLOCATIOXS. 


339 


/     Iliac 

Pubic    \ 

\ 

/              50 

7 

\ 

\    Ischiatic  . 

Obturator 

\              30 

II 

1 

luxations:  (1)  Upon  the  dorsum  ilii;  (2)  into  the  iscMatic  notch;  (3) 
into  the  obturator  foramen ;  (4)  upon  the  os  pubis.  Practically  these 
lesions  occnr  in  each  of  the  quadrants  of  a  circle,  the  center  of  which  is 
the  center  of  the  acetabulum. 

As  shown  in  Fig.  366,  about  50  per  cent  of  all  luxations  at  the  hip 
occur  in  the  iliac  quadrant,  30  per  cent  in  the  ischiatic,  11  per  cent  in  the 
obturator,  and  7  per  cent  in  the  pubic.    Two  per  cent  occur  beyond  these 
regions.      Cases  are  on  record 
where  the  head  of  the  bone  was 
lodged   on  the  tuber  ischii,   in 
the  perinaeum,  and  Just  beneath 
the  anterior -superior   spine   of 
the  Uiuni. 

The  capsule  is  usually  torn 
at  its  inferior  and  posterior  sur- 
face. It  may  be  a  slit  or  tear 
in  the  long  axis  of  the  liga- 
ment, or  frequently  a  broad 
rupture  occurs  along  the  edge 
of  the  cotyloid  cavity.  The 
ligamentum  teres  (when  pres- 
ent) is  always  torn.  The  ilio- 
femoral (or  Y)  ligament  is  very 
rarely  completely  ruptured.  The 
injury  to  the  muscles  and  sur- 
rounding  structures   is   always 

severe,  and  varies  in  proportion  to  the  degree  of  violence  which  caused 
the  luxation,  together  with  the  particular  direction  of  the  displace- 
ment. 

In  the  displacement  upon  the  dorsum  ilii  the  glutei  muscles  may  be 
lacerated,  bruised,  or  lifted  fi'om  the  Uium  by  the  head  of  the  bone,  but 
not  by  tension  on  their  tendons,  for,  with  the  exception  of  the  lower 
fibers  of  the  maximus,  their  axes  are  slightly  shortened  in  the  new  posi- 
tion. The  obturator  intemus,  extemus,  gemelli,  and  quadi-atns  femoris 
are  greatly  stretched,  or  torn  entirely  loose.  The  pyriformis  is  not  so 
apt  to  suffer.  The  pectinens,  iliacus,  and  psoas  are  carried  upward  and 
outward.  When  the  head  of  the  bone  is  projected  into  the  ischiatic 
notch,  the  conditions  as  to  the  muscles  are  practically  unchanged.  The 
sciatic  nerve  and  vessels  are  pressed  upon  and  may  be  contused  or  lacer- 
ated. In  the  displacement  upon  the  pubes  the  psoas  and  iliacus  may  be 
injured,  while  the  femoral  vessels  and  anterior  crural  nerve  are  more  or 
less  pressed  upon.  "When  the  head  of  the  bone  is  lodged  in  the  obturator 
foramen,  the  obturator  externus  muscle  and  the  obturator  vessels  and 
nerves  are  more  or  less  contused,  while  the  glutei  and  the  remaining 
external  rotators  are  put  upon  the  stretch. 

Causes. — Dislocations  at  the  hip  may  be  congenital,  pathological,  or 
traumatic  in  cause. 

Congenital  luxations,  rare  in  occurrence,  are  the  result  of  interference 


Fig.  366. — Showing  the  proportion  of  displacement  in  the 
four  quadrants  of  a  circle  about  the  acetabulum. 


340 


A  TEXT-BOOK   ON  SURGERY. 


with  normal  development.  Failure  to  complete  the  process  of  ossification 
in  the  three  bones  which  compose  the  acetabulum  leaves  a  soft  and  fibro- 
cartilaginous cup  or  sac,  through  which,  when  the  weight  of  the  body  is 
sufficient,  the  head  of  the  femur  is  more  or  less  completely  displaced  into 
the  pelvic  cavity.  Absence  of  the  ligamentum  teres  is  not  alone  sufficient 
to  account  for  displacement  when  the  bones,  capsule,  and  muscles  are 
normal,  for  it  is  not  infrequently  absent  in  cases  which  have  never  suf- 
fered a  luxation.  Moreover,  the  majority  of  cases  in  which  this  ligament 
has  been  ruptured  by  one  luxation  do  not  suffer  a  second  displacement. 
An  abnormally  long,  loose,  or  relaxed  capsule  will  lead  to  sub-luxation 
or  displacement  without  rupture  of  the  capsule.  Failure  of  development 
from  the  cervical  epiphysis  is  another  cause  of  congenital  dislocation  at 
the  hip. 

Patliologlcal  dislocations  are  caused  by  chronic  arthritis.  The  bones 
are  more  or  less  destroyed,  and  the  capsule  breaks  down,  permitting  dis- 
location of  the  head  of  the  bone  as  a  result  of  muscular  action  or  slight 

violence. 

Traumatic  luxations  are  dli^ect  or  indi- 
rect. The  most  frequent  cause  is  a  fall 
from  a  height  or  from  a  carriage  in  mo- 
tion, the  person  striking  upon  the  foot  or 
knee,  with  the  thigh  carried  in  such  a  di- 
rection that  its  axis  is  at  a  considerable 
angle  to  that  of  the  spinal  column. 

Anatomically  considered,  the  most  fa- 
vorable position  for  the  two  posterior,  and 
by  far  the  most  frequent  displacements,  is 
when  the  thigh  is  flexed  at  about  an  angle 
of  90°  to  the  axis  of  the  body.  If  the 
thigh  be  adducted,  the  tendency  is  to  rupt- 
ure the  capsule  on  its  posterior-inferior 
surface,  with  escape  of  the  head  on  to  the 
dorsum  ilii,  or  into  the  ischiatic  notch. 
When  in  a  position  of  abduction,  the  rupt- 
ure is  likely  to  occur  on  the  lower  anterior 
aspect  of  the  capsule. 

A  fall  directly  iipon  the  trochanter,  with 
the  thigh  in  adduction  or  abduction,  with 
extreme  outward  or  inward  rotation,  is  apt 
to  produce  rupture  of  the  capsule  and  lux- 
ation. 

Symptoms.  —  In  dislocation  upon  the 
dorsum  ilii,  with  the  patient  standing  erect 
upon  the  uninjured  extremity,  the  trochan- 
ter of  the  displaced  femur  will  be  nearer 
the  anterior- superior  spine  of  the  ilium  than 
that  of  the  opposite  side  ;  the  thigh  is  slightly  flexed  upon  the  abdomen, 
adducted,  and  rotated  inward.    The  head  of  the  bone  may  be  appreciated 


Fig.  367.— Position  of  extremity  in  dis- 
location of  the  liead  of  the  femur  upon 
the  dorsum  ilii.     (After  Hamilton.) 


DISLOCATIONS. 


341 


in  the  new  position.  The  shortening  is  from  one  to  two  inches,  and  in 
the  vast  majority  of  cases  the  great  toe  of  the  injured  side  is  directed  to 
or  rests  upon  the  instep  of  the  opposite  foot,  while  the  knee  of  the  lux- 
ated side  is  in  front  of,  and  slightly  above,  its  fellow  (Fig.  367).  Muscu- 
lar rigidity  and  fixation  are  extreme.  In  very  exceptional  cases  there  is 
eversion  of  the  foot,  with  slight  abduction,  which  Prof.  Bigelow  holds  to 
be  due  to  extensive  and  unusual  laceration  of  the  ilio-femoral  ligament. 

When  the  head  of  the  bone  is  lodged  in  the  iscMatic  notcJi,  the  gen- 
eral characters  of  the  deformity  are  the  same,  yet  not  so  well  marked. 
The  degrees  of  flexion  and  adduction  are  less  extreme,  the  trochanter  is 
less  prominent,  and  there  is  not  so 
much  shortening. 

In  the  thyroid  displacement  the 


iio.  368. — Position  of  extremity  in  dislocation  of 
the  head  of  the  femur  into  tlie  thyroid  foramen. 
(After  Hamilton.) 


Fig.  369. — Position  of  extremity  in  dislocation  of  the 
head  of  the  femm'  upon  the  pubes.  (After  Ham- 
ilton.) 


extremity  is  increased  in  length,  and  the  thigh  is  abducted  and  slightly 
flexed  upon  the  abdomen.  The  toes  may  be  turned  slightly  in  or  out, 
although  they  usually  point  to  the  front.  The  hip  is  less  prominent  than 
normal.  The  head  of  the  femur  may  at  times  be  recognized  in  the  new 
position,  although,  on  account  of  the  tense  condition  of  the  adductor 
muscles,  this  is  in  some  instances  impossible  (Fig.  368). 


342 


A  TEXT-BOOK   ON  SUEGERY. 


When  the  dislocation  occurs  on  the  pubes  there  is  abduction,  slight 
flexion,  and  slight  outward  rotation.  The  foot  is  carried  away  from 
that  of  the  sound  side,  and  the  toes  are  pointed  outward.  The  chief 
diagnostic  feature  of  this  displacement  is  the  presence  of  the  head  of  the 
bone  at  Poupart's  ligament  (Fig.  369). 

The  differential  diagnosis  is  between  muscular  spasm  or  rigidity  and 
fracture. 

Spasm  or  rigidity  of  the  muscles  about  the  hip  may  occur  as  a  re- 
sult of  an  acute  or  subacute  inflammatory  process  in  the  joint,  or  in 
the  periarticular  tissues,  or  in  certain  cases  of  ostitis  of  the  lumbar 
vertebrae,  sacrum,  or  ilium,  in  the  neighborhood  of  the  psoas  and  ilia- 
cus  muscles.  This  condition  of  partial  immobility  may  be  differentiated 
from  that  of  dislocation  by  the  absence  of  the  shortening,  which  is 
present  in  the  displacement  on  the  dorsum  ilii  and  into  the  ischiatic 
notch,  the  lengthening  in  the  thyroid  luxation,  while  the  head  of  the 
bone  on  the  pubes  will  determine  the  character  of  this  lesion.  The 
absence  of  the  characteristic  deformity  of  each  of  these  forms  of  dislo- 
cation will  determine  the  diagnosis  of  muscular  spasm  or  rigidity.  The 
symptoms  of  fracture  near  the  hip  have  been  given.  Shortening,  pre- 
ternatural mobility,  and  crepitus  are  to  be  chiefly  relied  upon  in  differ- 
entiation. 

deduction — Dislocation  on  the  Dorsum  Ilii — Bigelow's  Method. — 
In  complete  ether  narcosis,  place  the  patient  upon  a  strong,  low  table,  or 
upon  the  floor,  in  the  dorsal  decubitus.  Grasp  the  leg  of  the  dislocated 
side,  just  above  the  ankle,  with  one  hand,  and  near  the  knee  with  the 

other,  flex  the  leg  on  the  thigh,  and  the 
thigh  on  the  abdomen,  to  nearly  an  angle 
of  90°  with  the  surface  of  the  floor,  ad- 
duct  the  thigh  until  the  knee  of  this  side 
is  carried  to  about  the  middle  of  the  sound 
thigh,  and  then  cause  the  knee  to  describe 
a  circle  outward  and  downward  until  the 
leg  is  brought  to  the  floor  in  its  normal 
position  (Fig.  870).  If  the  luxation  is  not 
reduced  the  manoeuvre  should  be  careful- 
ly repeated.  This  method  of  reduction 
by  manipulation  is  based  upon  the  resist- 
ance to  reduction  which  is  made  by  the 
ilio-femoral  ligament  (when  this  is  not 
torn). 

The  normal  position  of  this  ligament 
is  shown  in  Fig.  371,  and  its  relaxation 
by  flexing  the  dislocated  thigh  upon  the 
abdomen  is  shown  in  Fig.  372 ;  and  it  is 
readily  seen  that  if,  with  the  thigh  in  this 
position,  abduction,  with  outward  rota- 
tion, is  practiced,  the  head  of  the  bone  will  be  lifted  over  the  margin  of 
the  acetabulum  and  carried  in  the  direction  of  the  socket. 


Fig.  370. — Reduction  of  dislocation  on  tte 
dorsum  ilii  by  manipulation.  (After 
Bigelow.) 


DISLOCATIONS. 


343 


Fig.  371. — The  ilio-femoral  or  Y  ligament. 
(Bigelo'n-.) 


Fig.  3T2. — Eelaxation  ol'  lU  i.i.j-;^iiioral  ligament  by 
flexion  and  adduction  of  tliigh.     (Bigelow.) 

Crosby^ s  MetTiodJ* — Place  the  pa- 
tient on  the  floor,  in  the  dorsal  decn- 
bitns.  Flex  both  legs  on  the  thigh, 
and  the  thighs  on  the  abdomen,  and, 
with  the  arms  locked  underneath  the 
knees,  raise  the  patient  fi-om  the 
floor  so  that  the  body  will  rest  only  on  the  neck  and  shoulders.  If, 
after  suspension  lasting  two  or  three  minutes,  reduction  is  not  accom- 
plished, the  patient  should  be 
swayed  from  side  to  side,  thus 
adding  alternately  slight  abduc- 
tion and  adduction  to  the  exten- 
sion. While  the  displacement  may 
be  overcome  without  ansesthesia, 
it  is  much  more  easily  and  surely 
effected  with  it. 

The  same  result  may  be  accom- 
plished by  employing  vertical  ex- 
tension in  the  manner  recommend- 
ed by  Bigelow  and  sho\vn  in  Fig. 
373. 

Hamiltoris  Method. — The  pa- 
tient is  in  the  dorsal  decubitus, 
and  the  limb  is  grasped  as  in  Bige- 
low's  method.  "  Flexing  the  leg 
on  the  thigh,  the  knee  is  to  be 
carefully  lifted  toward  the  face  of 

the    patient,    until    it    meets    with       p,,.  .3.3._Eednction  of  dislocation  on  the  dorsum  im 
some   resistance  ;   it   must    then    be  by  vertical  extension.     (Bigelow.) 


*  This  method  was  introduced  by  the  late  Prof.  A.  B.  Crosby. 


344 


A  TEXT-BOOK  ON  SUKGERY. 


Fig.  374. — Cooper^s  method  of  extensioi;i  and   counter-e.^tension  in 
reduction  of  dislocation  iilto  tlie  iscliiatic  notcli.     (Hamilton.) 


moved  outward  and 
sliglitly  rotated  in  the 
same  direction,  nntil  re- 
sistance is  again  en- 
countered, when  it  must 
be  brought  downward 
again  to  the  bed." 

The  older  method  of 
violent  extension,  by 
means  of  blocks  and 
pulleys,  should  not  be 
employed,  unless  all 
other  means  have  failed. 
Reduction  of  Dis- 
locations into  the  Is- 
chiatic  Notch. — In  this 
luxation  the  mechan- 
ism of  reduction  is  prac- 
tically the  same  as  for 
the  preceding  displace- 
ment. One  point  must 
be  giiarded  against  — 
the  danger  that,  when 
the  head  of  the  femur  reaches  the  margin  of  the  acetabulum,  it  may  be 
deflected  below  the  rent  in  the  capsule,  and  lodge  in  the  thyroid  foramen. 
If  extension  and  counter-extension  after  the  older  method  (Astley 
Cooper's)  be  necessitated,  the  pelvis  should  be  fixed  by  a  sheet  folded 
and  passed  through  the  peri- 
naeum  and  over  the  groin,  and 
extension  made  from  above  the 
knee,  with  the  thigh  flexed  al- 
most to  an  angle  of  90°  with 
the  abdomen,  and  adducted  un- 
til the  knee  is  carried  in  front 
of  the  opposite  thigh  (Fig.  374). 
Reduction  of  Dislocations  in 
the  Thyroid  Foramen — Method 
of  Bigelow. — Place  the  patient 
upon  the  floor,  in  the  dorsal  de- 
cubitus, flex  the  leg  on  the  thigh, 
and  the  thigh  on  the  abdomen, 
making,  at  the  same  time,  slight 
abduction.  Then  rotate  the  fe- 
mur inward,  adduct,  and  carry 
the  knee  to  the  floor. 

The  older  method  involved 
extension  in  a  lateral  direction,        „     ,^r    tj  ,   .■      <^  v  i     .•     •  .  .i    ..     -a 

'  riG.  375. — Eeduction  of  dislocation  into  the  thyroid 

by  means  of  a  sheet  folded  and  foramen.   (Bigeiow.) 


DISLOCATIONS. 


345 


Fig.  376. — Showing  the  relation  of  the  ilio-femoral 
ligament  in  dislocation  of  the  head  of  the  fe- 
mur int-o  the  thyroid  foramen.     (Bigelow.) 


pulleys  can  not  be  had,  tlie  sheet 
should  be  tied  into  a  loop 
and  laid  over  the  shoulder 
of  the  operator. 

Reduction  of  Dislo- 
cations upon  the  PiCbes 
— Hamilton's  Method. — 
When  the  head  of  the 
bone  is  lodged  well  over 
the  pelvic  rim  the  thigh 
should  be  abducted  and 
rotated  outward,  in  order 
that  the  head  may  be 
thus  lifted  over  the  pu- 
bes,  and  then  flexed  upon 
the  body,  adducted,  and 
brought  down.  Eotation 
outward  should  cease  as 
soon  as  the  head  of  the 
bone  has  risen  above  the 
pubes.  When  the  head 
has  not  passed  above  the 
rim  of  the  pubes,  out- 
ward rotation  is  not  called 
for. 


Fig.  377. — Showing  how  flexion  oi  t'l.c  thigh  on  the 
abdomen  relaxes  the  Uio-iemoral  li^ment  in 
dislocation  into  the  thyroid  foramen.  (Bigelow.) 

passed  around  the  inner  surface  of 
the  thigh,  while  the  pelvis  was 
fixed  by  a  sheet  passed  around 
this  part  of  the  body,  and  upon 
which  traction  was  employed  in  an 
opposite  direction  (Tig.  378).  If 
which  is  carried  around  the  thigh 


■Cooper's  method  of  reducing  dislocation  into  the  thy- 
roid foramen.     (Hamilton.) 


346,  A  TEXT-BOOK  ON  SURGERY 

If  in  this  manoeuvre  tlie  bone  slips  into  the  thyroid  foramen,  the 
manipulation  given  for  this  luxation  should  be  practiced. 

By  Extension  and  Counter -Extension — Hamilton's  Method. — Place 
the  patient  upon  the  edge  of  a  bed  or  table,  so  that  the  injured  limb  may 


Fig.  379. — Eeduction  of  dislocation  upon  the  pubes  by  extension  and  counter- extension.     (Hamilton.) 

fall  slightly  over  the  edge.  Extension  is  made  from  the  thigh,  and 
counter- extension  from  the  peringeum  and  groin,  in  the  direction  indi- 
cated in  Fig.  379. 

The  after-treatment  of  hip-luxation  involves  fixation  of  the  muscles 
about  the  joint  for  "from  two  to  six  weeks.  A  gutta-percha,  heavy 
pasteboard,  or  leather  splint,  molded  to  the  side  of  the  pelvis,  thigh, 
and  down  to  the  ankle,  applied  upon  a  thin  layer  of  absorbent  cot- 
ton, and  held  in  place  by  a  leg-,  thigh-,  and  spica-bandage,  should  be 
employed. 

The  prognosis  as  to  rapid  restoration  of  function  is  not  always  favor- 
able. The  injury  to  the  capsule,  and  more  especially  to  the  muscles 
around  the  joint,  may  lead  to  an  impairment  of  the  hip,  more  or  less 
permanent.  In  permanent  luxations,  in  some  instances,  a  fair  degree  of 
mobility  may  be  developed.  Eeduction  has  been  successfully  performed 
as  late  as  four  and  six  months  after  the  injury. 

'  The  treatment  of  congenital  dislocations  of  the  hip,  and  of  pathologi- 
cal luxations,  will  be  given  later. 

Dislocations  at  the  Knee — The  Tibia  from  the  i^e???  Mr.— Displace- 
ment of  the  femoral  end  of  the  tibia  may  occur  as  a  result  of  congenital 
malformation,  disease,  or  accident. 

Congenital  luxation  is  rare,  and  is  usually  partial.  As  a  rule,  the 
tibia  is  displaced  forward,  although  the  opposite  condition  may  prevail. 
Absence  of  the  patella  has  been  observed  in  several  of  these  cases. 

PatJtological  dislocations  will  be  given  under  the  head  of  diseases  of 
this  joint. 

Traumatic  luxation  at  the  knee  is  comparatively  rare.  The  tibia 
may  be  completely  or  partially  displaced,  and  in  any  direction.  Partial 
dislocation  is  the  rule.  Complete  luxation  is  apt  to  be  complicated  with 
a  wound.  A  compound  dislocation  usually  occurs  forward  or  backward. 
The  cause  is  direct  violence.  A  blow  upon  the  anterior  aspect  of  the 
tibia,  near  the  joint,  or  the  posterior-inferior  portion  of  the  femur,  may 


DISLOCATIONS. 


347 


cause  a  bacJcioard  displacement  of  the  tibia,  while  violence  from  opposite 
directions  may  produce  a.  forward  dislocation.  The  same  force  applied 
laterally  may  also  produce  the  lateral  displacements.    A  favorable  condi- 


kir, 


W/i>^ 


Fig.  379  a. — The  author's  case  of  backward  dislocation  of  the  tibia  at  the  knee,  caused  by  stepping;  into  i 
hole  while  in  the  act  of  running.     (From  a  drawing  by  Di.  Mewborn,  fifteen  years  after  the  accident.) 


Fig.  379  e. — The  same,  after  exsection. 


tion  for  luxation  is  the  application  of  violence  when  the  leg  is  in  extreme 
flexion.  A  sudden  twisting  or  wrenching  of  the  femur  upon  the  tibia  when 
the  foot  is  so  caught  that  rotation  on  the  heel  is  impossible,  is  favorable 
to  rupture  of  the  ligaments,  and  lateral  or  oblique  incomplete  luxation. 

The  symptoms  of  dislocation  at  the  knee  are  usually  clear.  In  the 
backward  variety  the  antero-posterior  diameter  of  the  knee  is  increased, 
the  tibia  projects  into  the  popliteal  space,  and  the  condyles  of  the  femur 
are  unusually  prominent.  In  the  forward  variety  the  antero-posterior 
measurements  are  also  increased,  the  anterior  edges  of  the  tibia  are  easily 
detected  in  the  advanced  position  of  this  bone,  while  the  condyles  of  the 
femur  are  unusually  prominent  posteriorly.  The  tibia  may  be  rotated 
upon  its  axis.  In  the  lateral  displacements  the  condyle  of  the  femur  is 
recognized  as  projecting  on  one  side,  while  the  flat  end  of  the  tibia  is  felt  on 
the  opposite  side.  The  transverse  diameter  of  the  joint  is  increased  in  pro- 
portion to  the  degree  of  displacement,  which  is,  however,  rarely  complete. 

Treatment. — Reduction  is  readily  effected  by  extension  and  counter- 
extension,  with  direct  pressure  and  counter-pressure  in  the  proper  direc- 


348  A  TEXT-BOOK   OJST   SURGERY. 

tions.  Once  reduced,  fixation  should  be  secured  by  Buck's  extension,  witli 
sand-bags  applied  to  the  limb,  or  an  investing  splint  should  be  employed. 

The  prognosis  after  this  injury  is  unfavorable.  The  function  of  the 
joint  is  rarely  fully  restored.  The  question  of  amputation  after  disloca- 
tions of  the  knee,  vrhere  there  is  extensive  injury  of  the  surrounding 
structures,  is  one  of  great  importance.  Shock  is  more  profound  in  this 
luxation  than  in  dislocation  at  any  other  joint.  A  primary  amputation 
will  rarely  be  justified  except  after  laceration  of  the  popliteal  vessels.  All 
antiseptic  measures  should  be  employed,  and  amputation  only  advised 
after  every  eifort  consistent  with  the  safety  of  the  patient's  life  has  been 
made.  Exsection  is  preferable,  and  ofiiers  not  only  a  greater  degree  of 
safety  but  a  more  useful  result. 

Dislocation  of  the  Patella. — This  bone  may  be  displaced  by  muscular 
action,  without  the  aid  of  external  violence,  or  by  an  injury  alone. 
When  the  ligamentum  patellae  is  ruptured,  it  is  carried  upward  for  a 
varying  distance  by  the  contraction  of  the  quadriceps.  It  can  only  be 
displaced  clowmoard  by  a  blow  received  upon  its  upper  margin  sufficient 
to  tear  it  loose  from  its  muscular  attachments.  Dislocation  outtoard  is 
the  more  frequent  variety,  and  occurs  as  a  result  of  muscular  contraction 
and  from  violence.  Displacement  inward  is  the  result  of  a  blow  received 
upon  the  outer  margin  of  the  bone.  In  the  lateral  dislocations,  in  rare 
instances,  the  patella  is  turned  obliquely  on  its  edge,  or  it  may  possibly 
be  completely  inverted. 

The  symptoms  of  these  various  luxations  are  unmistakable,  and  the 
reduction,  by  relaxing  the  quadriceps  and  pressure,  not  difficult. 

The  after-treatment  is  directed  to  the  prevention  of  recurrence. 

Dislocations  at  the  AnTcle- Joint. — Dislocations  at  the  tibio-tarsal 
articulation  may  occur  in  four  directions,  viz.,  forward,  hacJcward,  in- 
ward, and  outward.  In  the  last  two  forms  fracture  of  one  or  the  other 
malleolus  is  apt  to  occur. 

Dislocation  of  the  tibia  inward,  is  caused  by  a  fall  upon  the  foot  at  a 
time  when  it  is  turned  outward,  the  body-weight  being  brought  to  bear 
upon  the  inner  aspect  of  the  heel  and  great  toe.  This  form  of  sprain  is 
frequently  caused  by  leaping  from  a  wagon  or  car  in  motion.  It  may 
also  result  from  a  heavy  blow  upon  the  fibular  side  of  the  leg,  near  the 
ankle,  when  the  foot  is  solidly  fixed  against  the  ground.  The  displace- 
ment is  usually  partial.     A  complete  luxation  is  apt  to  be  compound. 

The  symptoms  of  inward  dislocation  are  the  great  prominence  of  the 
inner  malleolus  and  the  peculiar  twist  of  the  foot,  so  that  the  inner  side 
of  the  heel  and  the  great  toe  rest  on  the  floor  while  the  sole  looks  ob- 
liquely outward  and  upward.  The  only  displacement  it  may  be  mistaken 
for  is  that  of  the  astragalus  from  the  os  calcis. 

The  treatment  is  to  bring  the  foot  into  the  normal  position  by  pressure 
and  counter-pressure,  and  fix  it  with  a  splint  and  bandage.  On  account  of 
the  great  swelling  which  is  likely  to  occur,  an  immovable  dressing  should 
not  be  applied  until  the  aciite  symptoms  of  inflammation  have  subsided. 

The  symptoms  of  outward  displacement  are  the  reverse  of  the  inward, 
and  can  without  difficulty  be  recognized.     Displacement  of  the  tendons 


DISLOCATIONS.  349 

of  the  long  and  short  peronei  muscles,  from  their  sheaths  behind  the 
external  malleolus,  is  likely  to  occur  in  this  accident.  After  reduction 
at  the  joint  these  should  be  pushed  into  place,  and  an  effort  (rarely  suc- 
cessful) made  to  hold  them  in  position  by  a  compress  and  bandage,  ap- 
plied before  the  splint  for  the  luxation  is  adjusted. 

Forward  dislocation  may  occur  as  the  result  of  a  blow  upon  the  back 
of  the  leg,  near  the  ankle,  while  the  foot  is  firmly  placed  upon  the  ground  ; 
by  falling  forward  with  great  violence,  when  the  momentum  of  the  body 
is  suddenly  arrested  by  the  foot  striking  against  the  ground  ;  or  by  fall- 
ing backward,  with  the  foot  so  fixed  that  great  and  unusual  extension  of 
the  tarsus  takes  place. 

The  symptoms  are  unnatural  prominence  of  the  heel,  shortening  of  the 
distance  between  the  toes  and  the  front  of  the  tibia,  on  the  displaced  side. 

Reduction. — Place  a  clove-hitch  around  the  heel  and  instep  for  exten- 
sion, and  make  counter-extension  from  the  thigh.  Flex  the  leg  so  as  to 
relax  the  sural  muscles,  and  make  forcible  extension  from  the  foot.  As 
soon  as  the  extension  is  well  begun  the  operator  places  his  foot  against 
the  front  of  the  patient's  tibia,  just  above  the  ankle,  and  pulls  forward 
on  the  foot,  at  the  same  time  fiexing  it  on  the  tibia. 

Backward  displacement  is  caused  by  violence  applied  in  a  dii-ection 
opposite  to  that  which  produces  the/o/'wcwrZ  luxation,  and  the  symptoms 
are  exactly  the  reverse. 

The  treatment  demands  reduction  by  extension  and  counter-extension, 
and  direct  pressure. 

Dislocations  at  the  ankle  are  often  complicated  with  fracture,  or  may 
be  compound.  In  any  form  of  injury  an  effort  should  be  made  to  save 
the  foot  and  joint.  The  ankle  is  exceedingly  tolerant  of  surgical  inter- 
ference, and,  TOth  strict  cleanliness  and  antisepsis,  amputation  on  account 
of  complicated  or  compound  dislocation  will  be  rarely  necessary. 

The  fibula  may  be  displaced  from  its  articulation  with  the  tibia  at  its 
upper  or  lower  end.  At  the  upper  end  it  is  usually  luxated  forward,  as 
a  result  of  direct  violence  fi'om  behind,  although  it  is  possible  to  have  the 
reverse  occur.  The  bone  will  be  felt  in  the  abnormal  and  anterior  posi- 
tion, and  may  be  pushed  directly  back  into  place.  In  the  backward  dis- 
placement the  biceps  muscle  may  produce  the  luxation,  or  it  may  be  from 
violence  applied  from  the  front.  Strong  and  continued  pressure  must  be 
employed  to  retain  the  bone  in  position  until  adhesions  occur.  During 
the  treatment  the  leg  should  be  flexed  on  the  thigh  in  order  to  relax  the 
biceps. 

At  the  lower  end  dislocation  of  the  fibula  alone,  without  the  tibia,  is 
exceedingly  rare.  Anatomically,  it  may  occur  in  both  directions.  Re- 
duction may  be  effected  by  direct  pressure.  The  fibula  may  be  displaced 
outward  from  the  tibia  by  the  astragalus  being  driven  ujaward  between 
these  bones. 

Dislocations  of  t7te  Bones  of  the  Tarsus. — The  astragalus  may  be 
partially  or  completely  dislocated  forward,  backward,  outward,  or  in- 
ward. The  luxation  is  usually  incomplete.  On  account  of  the  great 
violence  necessary  to  its  production  it  not  infrequently  is  compound,  or 


350  A  TEXT-BOOK   ON   SURGERY. 

complicated  with  a  fracture.  Violence  of  the  same  character  as  that  which 
produces  displacement  of  the  tibia  will  cause  dislocation  of  the  astragalus. 

Treatment. — Luxation  of  the  astragalus  is  a  serious  accident.  The 
efforts  at  reduction  do  not  always  siicceed,  and,  eTOn  when  reduction  is 
effected,  the  injury  to  the  Joint  may  be  such  that  loss  of  function  results. 
Direct  pressure  and  counter-pressure,  while  the  patient  is  profoundly 
anaesthetized,  offer  the  best  means  of  successful  reduction.  Displace- 
ments of  the  metatarsal  bones  and  phalanges  of  the  toes  are  treated  in 
the  same  general  way  as  described  for  similar  lesions  of  the  hand. 

The  Yerte'brce. — Dislocation  may  occur  at  any  articular  surface  of  the 
vertebral  column.  The  accident  is  always  serious,  the  gravity  being  pro- 
portionate to  the  degree  of  displacement  and  the  injury  to  the  cord  and 
nerves. 

Luxations  are  more  common  in  the  cervical  region.  One  or  both 
articular  processes  may  be  displaced  forward  or  backward  upon  the  ver- 
tebra below.  In  the  unilateral  displacement  the  fibi'o-cartilage  between 
the  bodies  is  only  slightly  involved,  and,  w^hile  there  is  pressure  upon 
the  nerves  passing  oat  of  the  intervertebral  foramen,  there  is  no  pressure 
upon  the  cord.  In  the  bilateral  form  the  cartilage  is  torn,  the  body  more 
or  less  involved  in  the  luxation,  and  the  cord  compressed. 

The  causes  are  muscular  contraction,  or  violent  twisting  of  the  neck 
by  accident. 

The  symptoms  of  unilateral  displacement  are  pain — which  may  be 
referred  to  the  distribution  of  the  nerves  passing  through  the  interverte- 
bral foramen  involved — at  the  seat  of  luxation  and  rotation  of  the  head, 
in  a  forward  dislocation,  so  that  the  chin  points  to  the  side  opposite  to 
that  upon  which  the  injury  exists.  When  the  luxation  is  backward,  the 
face  is  tui-ned  toward  the  seat  of  injury. 

In  the  case  of  a  young  lady  which  came  under  my  observation,  the 
right  articular  process  of  the  fourth  cervical  vertebra  was  displaced  for- 
ward by  sudden  and  violent  muscular  contraction.  Pain  was  acute  at 
the  seat  of  luxation,  and  numbness  down  the  right  arm  indicated  com- 
pression of  some  of  the  filaments  fonning  the  brachial  plexus.  Reduction 
was  effected  as  follows :  The  patient  being  seated  in  a  chair,  the  shoul- 
ders were  held  immovable  and  the  head  further  rotated  to  the  left ;  then 
strong  extension  was  made  by  lifting  the  patient  from  under  the  chin 
and  occiput,  at  the  same  time  carrying  the  head  back  to  the  right.  Relief 
was  immediate  and  permanent. 

In  bilateral  luxation  careful  extension  and  direct  pressure  and  counter- 
pressure  should  be  practiced. 

Dislocation  of  the  condyles  of  the  occipital  bone  from  the  atlas  is 
probably  always  fatal.  Luxation  at  the  atlo-axoid  joint,  with  fx-acture 
of  the  odontoid,  is  also  fatal. 

Hibs. — The  ribs  may  be  displaced  from  their  vertebral  articulations. 
The  cause  is  direct  violence,  and  the  displacement  usually  forward.  The 
true  ribs  may  be  dislocated  at  the  junction  of  these  organs  with  their 
cartilages,  near  the  sternum.  The  treatment  for  these  luxations  is  the 
same  as  for  fracture. 


DISEASES  OF   THE  JOINTS.  351 

Diseases  of  the  Joints  iisr  General. 

The  simplest  form  of  inflammation  in  a  joint  is  that  of  the  synovial 
membrane  with  which  it  is  lined,  or  synovitis.  A  similar  condition  of 
the  sheaths  of  the  tendons  of  certain  muscles  is  known  as  thecitis. 

When  the  ligaments  of  a  joint  become  involved  in  the  inflammatory 
process  the  condition  is  known  as  syndesmitis ;  when  all  the  struct- 
ures of  the  articulation — as  bone,  cartilage,  ligaments,  synovial  mem- 
branes, etc. — are  involved,  it  is  an  arthritis,  or,  as  it  is  sometimes 
called,  osteo-arthritis. 

Synovitis  may  be  acute  or  chronic,  traumatic  or  idiopathic,  circum- 
scribed or  general.  It  may  precede  or  follow  a  syndesmitis.  If  the 
process  of  inflammation  in  the  lining  membrane  is  not  very  mild,  lasting 
only  a  few  hours,  it  must  of  necessity  involve  the  ligaments  upon  which  its 
basement-substance  rests.  On  the  other  hand,  a  peri-arthritis  which  in- 
vades the  ligamentous  structures  of  a  joint  will  also  produce  a  synovitis. 

The  process  of  inflammation  in  acute  synovitis  is  primarily  confined 
to  the  joint  capsule,  since  the  lining  membrane  is  not  reflected  on  to  the 
articular  cartilaginous  surfaces.  Hypereemia  and  dilatation  of  the  capil- 
laries in  the  basement  membrane  occurs,  followed  by  escape  of  leucocytes 
into  the  inter-capillary  spaces  and  into  the  capsule,  proliferation  of  the 
normal  epithelia,  and  general  effusion  into  the  cavity  of  the  joint. 

The  synovial  fluid  is  increased  in  quantity,  richer  in  cell-elements  than 
normal,  and  may  be  discolored  by  the  escape  of  red  blood-corpuscles  or 
free  hsematin.  The  result  of  this  process  is  distention  of  the  capsule  and 
communicating  burssB,  infiltration  of  the  basement  membrane  with  em- 
bryonic cells,  which  are  the  common  product  of  all  the  proliferating  cell- 
elements  in  the  tissues  involved. 

Synovitis  may  terminate  in  various  ways.  If  the  process  is  acute  yet 
mild,  and  all  the  conditions  of  the  individual  tissues  favorable  to  rapid 
repair,  resolution  may  occur  without  invasion  of  the  ligaments,  cartilages, 
or  bones.  The  escaped  corpuscular  elements  undergo  fatty  metamor- 
phosis, together  with  those  of  the  embryonic  tissue,  and  these  elements, 
with  the  excessive  fluid  in  the  capsule,  are  absorbed.  The  functions  of 
the  joint  are  soon  restored. 

Under  less  favorable  conditions  the  acute  process  may  pass  into  a  sub- 
acute and  chronic  synovitis  ;  the  embryonic  granulation- tissue  remains, 
the  normal  epithelial  lining  disajapears,  giving  way  to  a  dirty  fungus-like 
granulation-tissue,  which  thickens  the  entire  capsule  and  jjrojects  on  aU 
sides  into  the  cavity  of  the  joint.  The  ligaments  may  soften  and  ulti- 
mately break  down,  the  cartilages  become  eroded,  or  a  periostitis  and 
ostitis  may  be  precipitated  by  invasion  of  the  bone,  from  the  point  of 
junction  between  the  synovial  membrane  and  the  osseous  tissue — a  true 
artTiritis. 

The  causes  of  synovitis  are  predisposing  and  direct.  It  may  be  said 
that  any  dyscrasia  (which  in  itself  indicates  a  low  order  of  tissue-nutri- 
tion) encourages  the  development  of  a  synovitis,  and,  once  inaugurated, 
feebly  resists  its  progress.     Tuberculosis,  syphilis,  gout,  rheumatism,  the 


352  A  TEXT-BOOK   ON  SURGERY. 

eruptive  fevers,  traumatic  septicaemia,  and  gonorrhoea  may  be  mentioned 
as  the  chief  predisposing  conditions,  while  excessive  use,  a  blow  or  a 
sprain,  or  exposure  to  cold,  are  common  exciting  causes  of  synovitis. 

The  chief  symptoms  are  pain  and  swelling.  Under  direct  pressure  or 
motion  the  former  is  inci-eased.  Both  are  due  to  hypergemia  and  the 
distention  of  the  capsule  from  the  eflEusion.  Local  elevation  of  tempera- 
ture is  present. 

The  treatment  is  local  and  constitutional.  Rest,  in  the  position  of 
greatest  comfort,  is  essential.  Mild  extension,  to  a  degree  to  insure 
fixation,  affords  marked  relief  in  most  cases.  Cold,  applied  by  means 
of  the  ice-bag,  is  invaluable.  Heat  may  be  used,  as  hot  cloths,  the  hot- 
water  bag,  or  immersion  in  hot  water,  if  cold  is  distasteful  to  the  patient. 
Extreme  pain,  with  marked  distention,  should  be  immediately  relieved 
by  aspiration.  Among  the  many  useful  local  medical  remedies  are  lead- 
and-opium  wash,  vinegar,  solution  of  the  subacetate  of  lead,  and  various 
liniments.  Compression  by  means  of  absorbent  cotton  and  a  flannel 
bandage  is  useful  after  the  acute  symptoms  have  subsided. 

The  constitutional  treatment  looks  to  the  correction  of  any  existing 
disease,  the  administration  of  well-selected  articles  of  food,  and  tonics. 

When  synovitis  becomes  a  chronic  affection,  asj^iration  and  irriga- 
tion of  the  capsule  and  joint  are  the  most  effectual  methods  of  treatment. 
The  manner  of  operating  is  as  follows :  Shave  the  joint  to  be  operated 
upon  thoroughly,  and  wash  it  with  ether  and  with  l-to-3000  sublimate 
solution,  and  apply  a  disinfected  rubber  or  flannel  bandage  around  the 
part,  leaving  a  small  space  exposed  at  the  point  where  the  needle  is  to  be 
inserted.  Wash  out  the  instrument  and  needle  with  5-per-cent  car- 
bolic-acid solution.  Exhaust  the  aspirator,  push  the  needle  into  the 
joint  without  wounding  the  cartilage,  and  turn  on  the  stop-cock  which 
leads  into  the  vacuum.  When  the  flow  ceases,  close  the  cock,  empty 
the  cylinder  and  fill  it  with  1-to-lOOOO  corrosive-sublimate  solution,  and 
force  this  into  the  capsule,  to  its  full  distention  ;  then  exhaust  it,  place 
on  an  antiseptic  dressing,  and  compress  and  lock  the  joint  with  plas- 
ter of  Paris,  liquid-glass,  or  some  fixed  apparatus  or  splint.  This 
operation  may  be  repeated  as  often  as  needed,  always  guarding  against 
the  admission  of  air  to  the  capsule,  which  may  usually  be  prevented  by 
keeping  the  cylinder  of  the  aspirator  higher  than  the  needle.  The  air 
will  rise  and  remain  in  the  upper  chamber  of  the  instrument.  The  joint 
should  be  kept  quiet  for  about  six  weeks,  and  the  dressing  then  re- 
moved to  allow  careful  passive  motion.  If  the  fluid  has  re-accumulated, 
repeat  the  operation. 

Not  infrequently  a  synovitis  passes  uninterruptedly  on  into  an  arthri- 
tis, in  the  manner  already  described.  In  the  majority  of  instances, 
however,  the  destructive  lesions  of  the  joints,  which  obstinately  resist  all 
ordinary  methods  of  treatment,  commence  in  the  cancellous  tissue  of  the 
bone  in  the  immediate  vicinity  of  the  epiphyses ;  in  other  words,  destruct- 
ive artliritis  is  secondary  to  ostitis,  and  this  inflammation  of  bone  is 
almost  always  the  result  of  a  dyscrasia  and  an  accident  of  nutrition. 

The  opinion  which  has  prevailed — namely,  that  almost  all  lesions  of 


DISEASES   OF   SPECIAL  JOINTS.  353 

the  joints  were  caused  by  a  traumatism — has  been  proved  by  the  accu- 
mulated experience  of  many  accurate  and  conscientious  surgeons  to  be 
unscientific  and  without  foundation  in  fact. 

The  pathology  of  ostitis  has  been  dwelt  upon  on  a  previous  page. 
That  form  of  inflammation  of  bone  which  leads  into  arthritis  begins  in 
an  interference  with  the  normal  nutrition  of  the  growing  bones.  As 
stated,  the  primary  lesion  is  capillary  rupture  or  tuberculous  deposits  in 
the  cancellous  expansions,  near  the  articular  surfaces.  It  is  known  that 
in  growing  bones  rupture  of  a  vessel,  with  extravasation  of  blood,  is  very 
common,  even  in  healthy  children.  It  must  be  still  more  frequent  in 
those  children  suffering  from  any  dyscrasia  which  not  only  renders  the 
capillary  walls  less  strong,  but  lessens  the  reparative  power  of  the  tissues 
involved  in  the  area  of  extravasation. 

Tuberculous  ArtJiritis. — By  far  the  more  frequent  form  of  subacute 
and  chronic  arthritis  which  comes  under  the  surgeon's  observation  is 
tubercular  in  character.  Tuberculous  arthritis  may  originate  in  the 
deposit  of  the  hacilli  of  tuberculosis  directly  in  the  synovial  membrane 
or  articular  structures  proper  or  indirectly  by  invasion  from  foci  of  this 
disease  in  or  near  the  ejoiphyses  contiguous  to  the  joint.  Though  not 
uncommon  in  adult  and  older  life,  it  is  much  more  frequent  in  children. 
The  symptoms  of  tuberculous  joint  disease  vary  in  some  respects  owing  to 
the  direct  or  indirect  involvement  of  the  cavity.  There  is  also  a  marked 
difference  between  traumatic  arthritis  and  this  specific  form  of  infection. 

Aciate  arthritis  is  always  a  painful  affection,  and  is  almost  always 
traumatic  in  origin.  In  tuberculous  arthritis  pain  is  rarely  acute,  often 
absent  or  at  least  denied  by  the  patient,  and  most  frequently  present, 
but  intermittent  and  mild  in  character. 

When  the  tuberculous  deposit  is  primarily  met  with  in  the  capsule, 
the  interference  with  the  function  of  the  joint  is  not  material  until  the 
disease  has  so  far  progressed  that  disintegration  is  occurring.  The  joint 
is  usually  swollen  or  distended,  the  accumulation  of  fluid  at  times  being 
so  grave  as  to  require  aspiration,  but  not  infrequently  disappearing  rap- 
idly without  surgical  interference  to  refill  seemingly  without  periodicity 
and  without  an  exciting  cause. 

When  tubercular  ostitis  precedes  the  arthritis,  pain  of  a  mild  charac- 
ter is  more  apt  to  be  a  fixture.  In  all  of  these  cases,  however,  the  dys- 
crasia may  be  recognized  either  from  a  study  of  the  patient  or  of  the 
family  history. 

The  treatment  of  these  cases,  both  constitutional  and  local,  will  be 
taken  up  with  the  special  management  of  the  various  joints. 

Diseases  of  Special  Joints. 

Of  the  Hip. — Arthritis  of  the  hip,  hip-joint  disease  {inorTjus  coxa,  or 
morbus  coxariiis),  is  a  frequent  and  formidable  affection,  and  one  which, 
in  many  instances,  will  baffle  the  best  medical  and  surgical  care  through 
months  and  years  of  suffering,  ending  in  destruction  of  the  joint,  and 
frequently  in  death.  It  is  a  disease  of  childhood,  occurring  chiefly  in 
23 


354 


A  TEXT-BOOK   ON   SURGERY. 


Fig.  380. — Section  of  normal  femur  of  a  boy 
eight  years  old.     (After  Gibney.) 


the  period  of  rapid  growth.  It  rarely  occurs  after  the  twelfth  year. 
It  may  occur  at  any  time  prior  to  this  age,  the  majority  of  cases  being 
between  the  ages  of  three  and  six  years. 

The  pathology  of  morbus  coxae,  will  vary  with  the  peculiar  character 
of  the  lesion.  The  morbid  changes  which  occur  in  that  variety  which  is 
most  frequently  met  with  are  those  of  tubercular  ostitis,  primarily,  fol- 
lowed by  destructive  arthritis.  The  initial  lesion  occurs  as  an  inter- 
ference with,  or  arrest  of,  nutrition,  near  the  diaphyso-epiphyseal  carti- 
lage (Fig.  380,  a),  due  to  a  de- 
posit of  tuberculous  material 
at  this  location.  It  may  begin 
on  the  diaphyseal  or  epiphy- 
seal side.  According  to  Prdf. 
Gibney,*  the  initial  lesion  ap- 
pears in  several  centers  of  ossi- 
fication about  the  same  time. 
It  is  an  ostitis  rarefaciens. 
The  cancellous  cavities  become 
filled  with  embryonic  cells,  ab- 
sorption of  the  lamellee  occurs, 
the  inflammatory  new  products 
may  undergo  a  slow  process  of 
fatty  metamorphosis,  may  be- 
come caseous,  or  the  process 
may  terminate  in  pus-forma- 
tion. The  development  of  the  bone  is  arrested,  the  ostitis,  commenc- 
ing in  the  deeper  portions,  travels  in  all  directions,  destruction  of  the 
diaphyso-epiphyseal  cartilage  occurs,  with  separation  of  the  epiphy- 
ses {diastasis).  While  these  changes  are  going  on,  the  lining  mem- 
brane of  the  capsule  becomes  involved,  the  process  being  one  of  chronic 
synovitis,  which,  as  has  been  stated,  terminates  inevitably  in  inflamma- 
tory changes  in  the  tissue  proper  of  the  capsule.  The  joint  becomes 
filled  with  the  products  of  inflammation,  the  capsule,  over- distended 
and  weakened,  ruptures  either  spontaneously  or  as  a  result  of  motion, 
and  dislocation  may  occur.  With  separation  of  the  epiphysis  and  de- 
struction of  the  neck  of  the  femur  shortening  ensues. 

While  those  just  described  are  the  usual  morbid  changes  in  hip- 
disease,  in  other  cases  the  pathology  is  difl'erent. 

Morbus  coxcB  may  begin  as  a  simple  idiopathic  or  traumatic  synovitis, 
the  destruction  of  the  bone  being  secondary  and  commencing  from  the 
articular  surface,  progressing  inward.  It  may  commence  as  a  result  of 
injury  to,  or  arrest  of  nutrition  in,  the  digital  fossa  of  the  acetabulum, 
and  the  destruction  of  the  ligamentum  teres.  Again,  the  initial  ostitis 
may  be  situated  in  the  bones  which  form  the  cotyloid  cavity.  Lastly,' 
hip-joint  disease  may,  in  rarer  instances,  result  from  a  peri-articular 
inflammation,  first  a  syndesmitis,  secondly  a  synovitis,  lastly  arthritis. 

Causes. — The  causes  of   hip-disease  are  chiefly  predisposing.     Any 

*  "  The  Flip  and  its  Diseases,"  Bermingham  &  Co.,  New  York,  1884. 


DISEASES  OF  SPECIAL  JOINTS. 


355 


dyscrasia  which  impairs  nutrition  in  general,  tends  to  destructive  ostitis 
in  children,  and  consequently  to  the  resulting  arthritis.  Traumatism 
may,  and  undoubtedly  does,  precipitate  the  inflammatory  p>rocess  in 
many  cases,  yet  the  ordinary  violence  to  which  this  joint  is  subjected 
will  rarely  induce  coxitis,  except  in  children  aifected  with  some  constitu- 
tional disease.  Excessive  use  or  a  blow  may  produce  synovitis,  but,  in 
a  healthy  patient,  rapid  recovery  is  almost  certain.  If  diastasis  occurs 
as  a  result  of  accident,  ostitis  ensues,  and  destruction  of  the  joint  is  apt 
to  follow  ;  yet  this  is  an  exceedingly  rare  injury.  Rupture  of  the  liga- 
mentum  teres,  which  must  occur  in  a  trauniatic  luxation,  rarely  leads  to 
destructive  arthritis  in  an  otherwise  healthy  individual. 

The  symptoms  of  hip-disease  are  divisible  into  two  stages.  The  first 
stage  embraces  all  the  phenomena  of  inflammation,  up  to  a  positive  and 
appreciable  destruction  of  the  structures  which  enter  into  the  formation 
of  this  joint.  The  second  stage  embraces  the  phenomena  of  destruction, 
namely,  shortening  of  the  neck,  diastasis,  rupture  of  the  ligamentum  teres 
and  capsular  ligament,  and  luxation. 

Among  the  earlier  signs  of  this  disease  is  pain,  referred  directly  to  the 
hip,  or  it  may  be  to  the  hip-  and  knee-joint,  of  the  afifected  side,  and  in 
some  instances  the  pain  is  felt  wholly  in  the  knee  of  the  same  side.  This 
symptom  is  most  exaggerated  at  night  and  in  the  early  morning  hours, 
and  after  the  child  begins  to  move  about  may  disappear.  The  distribu- 
tion of  the  obturator  nerve  to  both  articulations  will  account  for  the  reflex 
sensibility  in  the  knee.  In  a  certain  number  of  cases  the  patients  will 
deny  all  sense  of  pam,  and  even  under  pressure  may  not  exhibit  signs  of 
suffering.  In  childi'en  this  effort  at  concealment  (not 
uncommon)  is  incited  by  the  fear  of  being  subjected 
to  surgical  treatment.  If,  however,  a  carefixl  exami- 
nation is  made,  rigidity  of  the  muscles  about  the  hip 
will  be  evident.  In  standing  erect,  the  weight  of  the 
body  will  be  brought  upon  the  sound  extremity,  the 
gluteal  fold  on  the  affected  side  is  partially  obliter- 
ated (Fig.  381),  and  in  walking  there  is  almost  always 


Fig.  382.— (After  Sayre.) 

a  perceptible  limp.  The  iliacus,  psoas,  and  adductor 
muscles  are  usually  in  an  abnonnal  state  of  tension  ; 
hence  the  initial  flexion  of  the  thigh,  and  outward 
rotation  or  eversion  of  the  foot. 
Rigidity  of  the  psoas  and  iliacus  muscles — one  of  the  more  positive 
early  symptoms  of  hip-disease — may  be  demonstrated  in  the  following 


FiQ.  381.— (Arter  S-iyre.) 


356 


A  TEXT-BOOK   ON   SURGERY. 


Fig.  383.— (After  Sayre.) 


Fig.  384.— (Alter  Say  re.) 


manner :  If  the  patient  be  stripped  and  laid  flat  on  the  back,  on  a  hard, 
level  surface,  and  both  legs  drawn  up  (Fig.  382),  it  will  be  seen  that  the 
sacrum,  spines  of  the  vertebrae,  the  scapulae,  and  occiput  rest  in  contact 
with  the  table.     If  the 
sound  leg  be  now  ex- 
tended and  the  pop- 
liteal   space    brought 
well  down  against  the 
surface  of    the   table, 
the    lumbar   spine    is 
only  very  slightly,  if 

at  all,  lifted  from  the  table  (Fig.  383).  If  there  be  rigidity  of  the  mus- 
cles named,  as  a  result  of  hip-disease,  on  the  suspected  side,  when  the 
effort  is  made  to  bring  this  leg  into  a  position  parallel  with  the  sound 

one,  it  will  be  seen 
that  extension  of  the 
thigh  is  limited,  and 
that  the  motion  of  the 
hip-joint  is  transferred 
to  the  lumbar  verte- 
brae, so  that  when  the 
popliteal  si^ace  touch- 
es the  table  the  himbar  spines  are  lifted  from  one  to  three  inches  from  its 
surface  (Fig.  384). 

The  duration  of  the  first  stage  varies  from  two  or  three  months  to  as 
much  as  one  year,  and  in  exceptional  cases  longer. 

In  the  second  stage  the  thigh  is  further  flexed  on  the  abdomen,  adduc- 
tion is  more  pronounced,  and  shortening  is  present  in  a  degTee  varying 
with  the  extent  of  destructive  ostitis  in  the  acetabulum,  or  head  and  neck 
of  the  femur,  and  to  the  character  of  the  luxation.  In  the  usual  position 
of  the  foot  of  the  affected  side,  in  this  stage,  the  great  toe  or  inner  surface 
of  the  tarsus  rests  upon  the  dorsum  of  the  well  foot,  or  on  the  spine  of 
the  tibia.  The  shortening — which  may  be  determined  by  measuring  from 
the  anterior-superior  sj)ine  of  the  ilium  to  the  inner  malleolus — will  vary 
from  half  an  inch  to  several  inches.  Nelaton's  or  Callaway's  test — 
already  given  in  the  article  on  fractures  of  the  femur — will  demonstrate 
that  the  shortening  has  occurred  above  the  trochanter. 

Suppuration  occurs,  the  capsule  gives  way,  and  sooner  or  later,  if 
surgical  interference  is  delayed,  sinuses  open  through  the  skin,  about  the 
trochanter,  or  in  the  groin.  Perforation  of  the  acetabulum  takes  place  in 
a  certain  proportion  of  cases. 

Diagnosis. — Disease  of  the  hip-Joint  may  be  differentiated  from  bur- 
sitis, peri-articular  inflammation,  rlieumatism,  neuralgia,  sacro-iliac  dis- 
ease, or  ostitis  of  the  trochanter  or  ilium.  It  is  also  important  to  deter- 
mine whether  the  initial  lesion  is  a  synovitis  or  an  ostitis. 

Synovitis  may  be  caused  by  excessive  use  of  the  joint,  by  strain  or 
concussion,  by  sudden  exposure  to  cold,  or  it  may  result  as  a  symptom 
of  gout  or  rheumatism.     It  is  a  painful  affection  from  its  incipiency,  and 


DISEASES   OF    SPECIAL   JOIXTS.  357 

the  pain  increases  with  the  march  of  the  effusion  into  the  Joint  and  the 
distention  of  the  capsule.  Motion  increases  the  pain,  which  is  usually 
so  severe  that  all  movement  of  the  Joint  is  firmly  resisted.  The  cause 
may  usually  be  traced  to  an  injury.  Synovitis  due  to  gout  or  rheuma- 
tism occui's  usually  in  adults ;  coxitis  is  practically  a  disease  of  child- 
hood. 

When  ostitis  is  the  initial  lesion,  the  approach  of  the  disease  is  insidi- 
ous and  much  less  painful.  When  present,  the  pain  in  ostitis  of  the  head 
and  neck  of  the  femur  is  deep-seated  and  dull,  and  motion  is  compara- 
tively free.  Eotation  and  pressure  of  the  head  upon  the  capsule  and  in 
the  acetabulum  do  not  produce  the  sharp  sense  of  pain  felt  in  synovitis. 
Ostitis  is  the  rule  in  children,  synovitis  in  adults. 

Bursitis  about  the  hip  is  rare.  The  sac  between  the  capsule  and  the 
conjoined  tendon  of  the  psoas  and  iliacus  muscles,  and  those  situated 
between  the  tendons  of  the  gluteus  maximus,  medius  and  minimus  and 
the  great  trochanter,  and  that  between  the  quadi-atus  femoris  and  the 
lesser  trochanter,  may  one  or  all  be  involved.  Inflammation  in  one  or 
more  of  these  burste  may  be  recognized  by  the  limited  extent,  as  well  as 
the  acuteness  of  the  pain  elicited  by  direct  digital  pressure  immediately 
over  the  known  position  of  the  sac.  Pain  in  the  knee  is  not  present  in 
bursitis  at  the  hip.  Eigidity  is  not  general  in  the  muscles  about  the 
Joint. 

Peri-articular  ivflammation  is  a  painful  affection,  causing  marked 
lameness  from  the  start  ;  it  is  accompanied  by  local  swelling  and  tender- 
ness if  superficial,  and  by  exacerbations  of  temperature,  all  of  which 
will  render  it  easy  of  recognition. 

Muscula,r  rheumatism  is  rarely  confined  to  the  muscles  of  the  hip. 
It  is  an  expression  of  a  constitutional  condition  which  can  not  but  be 
elicited  by  a  careful  history  and  study  of  the  case.  The  pain  is  more 
severe  and  more  early  recognized  than  iu  coxitis.  The  painful  temtory 
may  be  outlined  by  fixation  of  the  Joint  and  digital  pressure  upon  the 
muscles  involved. 

lifeuralgia.  occurs  very  rarely  in  children,  in  the  period  when  hip- 
disease  is  most  likely  to  appear.  The  exacerbations  of  pain  are  more 
sudden  in  development  and  acute  iu  character,  and  occur  with  greater 
frequency  and  regularity  than  in  hip-disease.  Motion  is  tolerated  better 
in  neuralgia  than  in  coxitis.  The  symptoms  of  ostitis  which  lead  to 
arthritis,  if  carefully  studied,  will  show  a  wide  difference  from  neuralgia 
about  the  hip. 

In  arthritis  or  ostitis  at  the  sacro-iliac  Junction  pain  is  caused  by 
forcibly  pressing  the  ilium  against  the  sacrum.  The  same  symptoms 
may  be  elicited  by  direct  pressure  posteriorly  over  the  sacro-iliac  articu- 
lation.    Motion  at  the  hip  is  only  slightly  if  at  all  embaiTassed. 

Prognosis. — In  hip-Joint  disease  commencing — as  is  the  rule — in 
ostitis  or  epipTiysitis,  the  jjrognosis  is  bad  as  regards  restoration  of 
function.  Partial  or  complete  anchylosis,  with  a  variable  degree  of 
shortening,  will  result,  in  the  vast  majority  of  cases,  no  matter  how 
skillfully  treated.     The  proportion  of  fatal  cases  can  scarcely  be  de- 


358  A  TEXT-BOOK   ON   SUKGERY. 

termined.  It  is  safe  to  say  that  at  least  twelve  per  cent  of  all  cases 
in  which  the  lesion  begins  as  an  ostitis  end  in  death  in  from  one  to  six 
years. 

In  traumatic  synovitis  of  the  hip  the  prognosis  is  favorable.  A  resto- 
ration of  function  is  the  rule. 

Treatment. — The  treatment  of  hip-disease  may  be  divided  into  me- 
chanical, operative,  and  constitutional. 

In  the  early  stage  of  coxitis  rest  to  the  inflamed  articulation,  in  the 
position  of  least  discomfort,  is  essential.  Fixation  of  the  muscles  which 
act  upon  and  about  this  joint  can  be  best  secured  by  extension  from  the 
lower  part  of  the  thigh  and  the  leg  or  foot,  and  counter-extension  from 
the  peringeiTm.  To  accomplish  extension  satisfactorily  the  limb  should 
be  brought  into  the  straight  position — that  is,  about  parallel  with  the  axis 
of  the  body. 

If  a  child  with  hip-disease  be  seen  very  early  in  the  history  of  this 
affection,  flexion  of  the  thigh  iipon  the  abdomen  will  not  have  occurred 
to  any  extent,  but,  in  cases  where  the  inflammatory  process  has  gone  on 
for  some  time,  the  iliacus  and  psoas  and  adductor  muscles  will  have  be- 
come rigid  and  shortened  to  such  an  extent  that  the  thigh  can  not  be 
immediately  brought  out  straight. 

In  the  former  class  of  cases  the  apparatus  about  to  be  described 
can  be  at  once  adjusted  ;  in  the  latter,  extension  in  the  recumbent 
posture  is  necessary  until  the  shortening  in  the  ilio-psoas  muscles  is 
overcome. 

In  fact,  since  in  all  cases  some  time  must  elapse  between  the  discovery 
of  the  lesion  and  the  preparation  of  the  mechanical  apparatus,  it  is  a  wise 
practice  to  put  the  patient  to  bed  at  once,  and  apply  the  extension  as 
foUows  :  Cut  two  strips  of  mole-skin  plaster,  from  one  inch  and  a  half  to 
two  inches  wide,  and  long  enough  to  extend  from  six  inches  above  the 
trochanter  to  below  the  sole  of  the  foot.  Adjust  one  to  the  outer  and 
one  to  the  inner  aspect  of  the  thigh,  allowing  the  upper  end,  which  is  to 
be  doubled  back  upon  itself  and  woven  in  with  the  roller,  to  extend  four 
or  five  inches  above  the  level  of  the  trochanters.  Mold  them  carefully  to 
the  contour  of  the  limb,  bringing  the  strips  exactly  over  the  inner  and 
outer  condyles  of  the  femur,  and  hold  them  by  a  well-adjusted  bandage, 
beginning  from  above.  In  order  to  prevent  the  plaster  from  wrinkling,  it 
is  necessary  to  clip  it,  at  intervals  of  an  inch  or  two,  with  the  scissors, 
obliquely  upward  from  each  edge.  The  strips  should  be  made  to  adhere 
to  the  skin  to  within  six  inches  of  the  malleoli,  not  so  much  that  traction 
below  the  knee  is  necessary,  but  because  the  complete  extension  of  the 
leg  on  the  thigh  enforces  more  perfect  quiet.  The  bandage  is  commenced 
just  at  the  level  of  the  great  trochanter,  and  that  portion  of  the  strips 
which  extends  above  this  is  to  be  turned  down  and  worked  in  with  the 
roller. 

That  part  of  the  plaster  which  is  exposed  near  the  foot  should  be 
doubled  by  laying  a  second  strip  of  equal  width  on  this,  the  adhesive 
surfaces  coming  together.  In  this  way  it  is  not  only  strengthened,  but  is 
prevented  from  sticking  to  the  dressing. 


DISEASES   OF  SPECIAL  JOINTS. 


359 


The  extension-weight — varying  from  two  to  seven  or  eight  pounds — is 

applied  as  in  Buck's  apparatus  (page  304).     The  dorsal  deciibitus  should 

be  maintained,  for,  if  the  sitting  posture  is  assumed,  the  iliacus  and 
psoas  muscles  are  not  materially  affected  by 
the  extension.  To  secure  this  result  the 
long  splint  of  Hamilton  should  be  applied 
from  the  axilla  along  the  thigh  and  leg,  and 
firmly  secured  by  a  bandage  carried  around 
the  chest,  jjelvis,  and  thigh. 

As  soon  as  the  thigh  is  fully  extended  the 
following  mechanism  should  be  adjusted. 
It  consists  of  a  long  Sayi-e  splint  (Fig.  385) 
and  the  high  shoe  and  crutches  of  Hutchi- 
son. The  splint  is  composed  of  a  long,  hol- 
low steel  shaft,  attached  above  to  a  pelvic 
belt  by  a  joint  capable  of  motion  in  every 
direction.  To  the  belt  two  perineal  bands 
are  attached.  Opposite  the  knee  a  strap 
and  i^ad  are  fixed,  which  serve  to  steady  the 
leg  at  this  joint.  Fitting  snugly  within  this 
hollow  shaft  is  a  bar  of  steel  which  may  be 
slid  up  or  down  by  a  ratchet  and  key,  and 
locked  in  any  position.  The  lower  end  of 
this  rod  is  tiarned  at  an  angle  of  90°  to  the 
Fig.  385.  shaft,  aud  fitted  with  a  spring- catch  into  a 

socket  on  the  sole  of  the  shoe.     In  applying 

the  instrument  shorten  the  shaft  as  much  as  possible,  fasten  the  belt 

around  the  pelvis  just  above  the  trochanters, 

and  then  the  perineal  bands,  one  on  either  side. 

The  shoe  is  put  on,  the  spring-catch  fixed  in  the 

socket  at  the  sole,  and  the  knee-pad  biackled. 

The  shaft  of  the  instrument  is  now  lengthened 

by  the  key  until  a  fair  and  comfortable  degree 

of  extension  is  secured.    The  shoe  upon  the  foot 

of  the  sound  side  should  be  raised  from  one 

inch  to  one  inch  and  a  half,  and  the  patient 

made  to  move  about  on  crutches.    Upon  retiring 

for  the  night  the  extension  employed  at  first 

should  be  resumed.    This,  the  combination  meth- 
od, is  shown  in  Fig.  386.     The  effectiveness  of 

this  plan  of  treatment  has  been  satisfactorily 

demonstrated  in  a  number  of  instances.     The 

advantages  are  :    1.  The  patient  is  able  to  move 

about  and  obtain  the  benefit  of  out-of-door  life, 

while  the  hip  is  held  in  extension  and  practical- 
ly immovable.     2.  The  high  shoe  and  crutches 

hold  the  lame  foot  and  leg  suspended.     3.  In     „     ,„„    „,       ,,    ,        , . 

o  1  FiQ,  386.— The   author's  combi- 

case  of  a  fall,  the  s^Dlint  prevents  concussion  in  nation  method. 


360  A  TEXT-BOOK   ON   SURGERY. 

the  joint.  4.  The  night-extension  prevents  spasmodic  contraction  of  the 
muscles  and  pain  from  unguarded  movements  during  sleep. 

The  length  of  time  for  which  this  treatment  should  be  continued 
vrill  be  determined  by  the  result  achieved.  It  is  often  a  necessity 
for  one,  two,  or  three  years,  and  sometimes  even  longer,  and  should 
be  worn  for  several  months  after  all  active  symptoms  of  coxitis  have  dis- 
appeared. 

The  constitutional  treatment  of  this  disease  is  of  great  importance. 
Carefully  selected  diet,  out-of-door  life,  cod-liver  oil  and  the  hypophos- 
phites  of  lime  and  soda,  and  tonics,  are  indicated. 

If  the  long  splint  can  not  be  obtained,  the  high  shoe  and  crutches 
should  be  used  while  the  patient  is  out  of  bed,  and  the  extension  em- 
ployed whUe  lying  down. 

In  the  second  stage  of  hip-disease  operative  interference  may  be 
demanded:  (1)  To  relieve  pain  on  account  of  suppuration  and  the  re- 
tention of  pus,  or  to  prevent  sepsis  from  insufficient  drainage ;  (2) 
to  arrest  ostitis  in  the  head  and  neck  of  the  femur,  and  in  the  ace- 
tabulum. 

When  pain  is  so  severe  that  fixation  with  extension  will  not  afford 
relief,  it  is  safe  to  conclude  that  distention  of  the  capsule  exists,  or  that 
in  the  structures  which  form  the  joint,  or  are  immediately  around  it, 
suppuration  has  occurred  to  such  a  degree  that  free  puncture  or  incision 
is  necessary.  For  this  purpose  the  aspii-ator  may  be  employed,  or  the 
bistoury. 

Although  the  propriety  of  opening  the  joint  freely  and  removing  all 
diseased  bone — exsection  of  the  hip-joint — when  positive  symptoms  of 
destructive  ostitis  are  present,  is  questioned  by  some  surgeons,  the 
weight  of  opinion  is  on  the  side  of  operative  interference. 

Admitting  that  probably  a  majority  of  all  cases  in  which  destruc- 
tion of  bone  occurs  recover,  with  more  or  less  complete  anchylosis, 
without  exsection  and  without  operative  interference  of  any  kind,  the 
drainage  through  the  sinuses  which  lead  out  through  the  skin  being 
sufficient ;  and  that  the  operation  is  not  without  danger  to  life  ;  and 
when  not  fatal  is  not  successful  in  all  cases,  the  ostitis  continuing  or 
recurring  after  exsection — the  argument  in  favor  of  operation  is  not 
answered. 

Exsection  of  the  hip-joint  is  not  a  dangerous  operation  when  done 
in  the  earlier  stages  of  destructive  osteo-arthritis,  before  the  patient's 
vitality  is  impaired  by  continued  suppuration,  septic  absorption,  and 
amyloid  changes  in  the  viscera.  Moreover,  in  the  cases  which  recover 
without  surgical  interference  the  dead  bone  and  products  of  inflammation 
must  be  carried  away  through  tortuous  channels,  in  which  absorption  is 
more  apt  to  occur  than  when  direct  drainage  is  established.  The  opera- 
tion removes  at  once  all  diseased  tissue  and  leaves  a  free  and  open  wound 
for  drainage. 

After  exsection  the  wound  should  be  packed  with  sublimate  gauze 
and  treated  by  the  open  method — not  even  partially  closed  by  sutures. 
The  gauze  may  be  changed  every  few  days,  the  wound  irrigated  with 


DISEASES   OF   SPECIAL   JOINTS. 


361 


l-to-3000  sublimate  solution,  and  again  filled.  Extension  by  the  weight 
and  pulley,  in  the  dorsal  decubitus,  is  necessary  for  from  three  to  six 
weeks  after  the  operation,  unless  the  child  is  strapped 
in  the  wii-e  breeches  recommended  by  Prof.  Sayre 
(Fig.  387)  immediately  after  the  exsection.  The 
chief  recommendation  of  this  apparatus  is  that  it 
allows  the  patient  to  be  carried  out  of  doors,  or 
about  the  house,  with  perfect  freedom  from  motion 
or  pain.  The  chief  objection  is  its  costliness,  which 
puts  it  out  of  the  reach  of  many  patients.  The  ex- 
tension in  bed  is  very  satisfactory  in  its  results,  and, 
vdth  attention  to  ventilation  and  the  amusement  and 
entertainment  of  the  little  patient,  the  confinement 
need  not  be  a  formidable  objection. 

When  the  wire  apparatus  is  used  the  following 
directions  should  be  carried  out :  Pad  the  instru- 
ment well,  so  that  too  great  pressure  at  any  one 
point  may  not  occur.  Place  the  patient  in  it  so  that 
the  anus  will  project  well  over  the  crotch  of  the 
breeches.  It  is  well  to  insert  a  piece  of  protective 
under  the  sacrum  and  buttocks  to  prevent  soiling. 
Fasten  the  well  leg  and  the  body 
to  the  instrument  by  rollers. 
Lay  the  extremity  of  the  affect- 
ed side  in  its  splint,  and  screw 
the  foot-piece  up  until  it  touch- 
es the  sole.  Apply  two  strips 
of  adhesive  plaster  in  the  same 
manner  as  heretofore  given,  at- 
tach these  to  the  foot-piece,  and 
make  the  necessary  extension  by  turning  the  screw 
in  the  proper  direction  (Fig.  388).  Passive  motion 
to  the  ankle  and  knee  should  be  made  at  the  end 
of  two  or  three  weeks,  and  repeated  weekly.  Af- 
ter from  four  to  six  weeks,  no  matter  whether  the 
wire  apparatus  is  used  or  extension  in  bed  employed, 
the  long  splint,  high  shoe  and  crutches  should  be 
adjusted,  and  the  case  treated  as  given  for  the  first 
stage. 

Within  the  last  few  years  the  operation  of  drill- 
ing into  the  neck  and  head  of  the  femur,  in  cer- 
tain cases  where  the  initial  lesion  is  an  ostitis,  has 
been  advocated  and  perfonned  in  a  number  of  instances  by  Mr.  Mac- 
namara.*    The  results   so  far  have   been  of  a  nature   to   encourage   a 
repetition  of  this  procedure.     The  object  of  the  operation  is  to  give  es- 
cape to,  and  secure  drainage  of,  the  products  of  the  inflammatory  pro- 


Fio.  387.— (After  Sayre.) 


(After  Sayre.) 


*  "  Gibney  on  the  Hip."     BermiDgham  &  Co.,  New  York,  18S4. 


362  A  TEXT-BOOK   ON  SURGERY. 

cess,  at  or  near  the  epiphysis,  and  thus  prevent  disintegration  of  the 
bone  and  invasion  of  the  joint.  To  be  beneficial  it  must  be  done  early 
in  the  process. 

The  operation  is  neither  dangerous  nor  difficult.  A  longitudinal  in- 
cision, from  two  to  three  inches  in  extent,  is  made  along  the  middle  of 
the  trochanter,  down  to  the  bone.  The  wound  should  be  deep  enough  to 
permit  the  fingers  to  locate  the  neck  of  the  femur,  on  its  upper  and  lat- 
eral surfaces,  so  that  the  drill  may  be  directed  along  its  center.  The 
chief  danger  to  be  avoided  is  entering  the  cavity  of  the  joint  by  carrying 
the  drill  too  far.  In  the  single  case  in  which  I  performed  this  ojjera- 
tion,  in  a  boy  about  eight  years  old,  a  button  of  bone  was  removed  by  the 
trephine  from  the  compact  substance  of  the  femur,  just  below  the  tro- 
chanter. A  drill,  about  three  sixteenths  of  an  inch  in  diameter,  was  then 
carried  up  through  the  neck,  a  distance  of  one  inch  and  a  quarter.  The 
direction  of  the  neck  was  readily  made  out  by  keeping  the  index-finger 
applied  to  the  upper  surface  of  the  neck  and  capsule.  After  the  oj^era- 
tion  a  rubber  tube  was  inserted,  and  through  this  drainage  maintained 
until  all  discharge  ceased. 

Knee-joint. — Acute  synovitis  of  the  knee  is  frequently  of  traumatic 
origin,  resulting  from  the  excessive  strain  to  which  this  joint  is  subjected, 
and  also  on  account  of  its  exposed  position.  It  may  occur  in  the  history 
of  gout,  rheumatism',  gonorrhoea,  and  other  diseases. 

The  chief  symptoms  are  pain  and  swelling.  Pain  may  be  elicited  by 
motion,  or  by  direct  pressure  at  any  part  of  the  joint,  but  it  is,  as  a  rule, 
emphasized  over  the  coronoid  ligaments,  along  the  articular  margin  of 
the  tibia,  on  either  side  of  the  ligamentum  patella. 

The  treatment  consists  of  rest  and  fixation.  As  a  rule,  the  most 
agreeable  position  is  that  of  slight  flexion,  with  the  limb  elevated  and 
the  leg  resting  over  a  pillow.  Fixation  may  be  best  secured  by  exten- 
sion from  adhesive  strips,  reaching  from  just  below  the  knee  to  beyond 
the  sole.  The  strips  are  applied  in  the  same  manner  as  above  given.  The 
weight  vsdll  vary  from  three  to  fifteen  i^ounds,  according  to  the  age  of  the 
patient.  Cold,  applied  by  means  of  the  ice  bag,  is  a  most  useful  remedy 
during  the  acute  stage  of  inflammation.  When  pain  is  very  severe,  and 
when  the  capsule  is  greatly  distended,  aspiration  is  indicated.  This 
should  be  done  with  all  antiseptic  precautions,  and  with  great  care  in 
preventing  the  entrance  of  air.  The  proper  instrument  is  shown  at  page 
65.  The  needle  may  be  introduced  on  either  side  of  the  patella,  at  the 
point  of  greatest  distention,  or  where  fluctuation  is  most  marked.  The 
diagnosis  may  be  made  positive  by  the  exploring  hypodermic  needle  and 
small  aspirator  (page  63).  Or,  when  the  tumefaction  is  evident  above  the 
patella,  the  needle  may  be  carried  from  above  downward,  behind  this 
bone.  After  the  excess  of  fluid  is  withdrawn  a  fair  degree  of  compres- 
sion should  be  exercised  by  enveloi:)ing  the  joint  with  borated  cotton, 
held  firmly  down  by  a  roller.  Passive  motion  of  the  joint  may  be  omitted 
for  as  long  as  four  weeks,  but  should  be  made  weekly  after  this. 

When  an  acute  synovitis  of  the  knee  becomes  rapidly  suppurative, 
ivith  the  symptoms  of  sejpsis,  which  are  common  to  this  form  of  disease, 


DISEASES   OF  SPECIAL  JOINTS.  363 

evacuation  of  the  pus  and  irrigation  of  the  joint  are  indicated.  The 
same  instrument  is  to  be  employed,  and,  after  the  fluid  is  withdrawn, 
the  capsule  is  distended  with  l-to-40  carbolic-acid  or  1-to-lOOOO  sublimate 
solution,  and  again  emptied.  This  operation  should  be  repeated  until 
the  liquid  comes  out  clear.  Compression  should  be  applied  in  the  same 
manner  as  before  given.  The  same  treatment  appUes  in  chronic  and  re- 
peated effusion  of  non-purulent  fluid  in  the  joints  (see  pages  852,  353). 

If  the  joint  refills  with  pus,  and  the  symptoms  of  sepsis  are  not  re- 
lieved by  aspiration  and  irrigation,  it  should  be  opened  and  free  drainage 
established.  It  is  safer  to  make  one  incision  on  either  side  of  the  patella, 
directly  into  the  capsule,  introduce  the  closed  dressing-forceps  and  bore 
through  the  ligament,  making  a  counter-opening  on  the  lower  lateral 
aspects  of  the  joint.  It  is  only  necessary  to  incise  the  skin  where  it  is 
pushed  out  and  made  tense  by  the  point  of  the  forceps.  The  hole  may 
be  enlarged  by  separating  the  blades  of  the  instrument.  A  drainage-tube 
should  be  caught  in  the  grasp  of  the  forceps  before  it  is  withdrawn,  and 
pulled  through  the  joint  as  the  instrument  is  removed.  The  irrigation 
may  be  constant  or  interrupted,  according  to  the  severity  of  the  symp- 
toms.    A  method  of  continuous  irrigation  is  shown  on  page  119. 

The  danger  of  anchylosis  after  acute  synovitis  of  the  knee-joint,  last- 
ing not  longer  than  from  one  to  six  weeks,  is  slight.  It  is  always  great 
after  suppurative  synovitis  and  arthritis,  and  in  osteo-arthritis  is  almost 
inevitable. 

Destructive  osteo-arthritis  of  the  knee-joint  may  commence  as  a  syno- 
vitis, either  traumatic  or  idiopathic,  or  it  may  begin  as  an  ostitis,  in  or 
near  the  epiphysis  of  the  tibia  or  femur,  the  joint  being  secondarily  in- 
volved. The  latter  is  by  far  the  more  frequent  source  of  chronic  knee- 
joint  disease. 

Symptoms. — Pain  is  not,  as  a  rule,  a  prominent  symptom  of  ostitis 
near  the  knee,  and,  when  the  joint  has  become  involved  and  the  carti- 
lages eroded,  in  many  instances  the  degree  of  pain  felt  is  far  from  being 
proportionate  to  the  gravity  and  extent  of  the  destructive  process.  In 
exceptional  cases  pain  may  be  excessive,  and  may  be  felt  in  the  hip  as 
well  as  the  knee,  or  may  be  referred  entirely  to  the  acetabulum.  As  the 
disease  progresses  the  swelling  increases,  and  is  due  not  only  to  efl'usion 
into  the  capsule,  but  also  to  thickening  of  the  ligaments,  and,  to  a  certain 
extent,  to  changes  in  the  ends  of  one  or  both  bones  which  enter  into  the 
formation  of  this  articulation.  Later  the  ligaments  give  way,  and  dislo- 
cation of  the  tibia  backward,  with  slight  outward  rotation,  occurs  (sub- 
luxation). In  the  earlier  stages  of  the  ostitis  certain  constitutional 
symptoms  appear,  and  remain  throughout  the  course  of  the  disease. 
Septic  fever  is  present  in  a  varying  degree,  and  with  it  impairment  of 
function  in  the  digestive  apparatus. 

Treatment.  — Whenever  destructive  ostitis,  with  arthritis,  at  the  knee 
exists,  the  loss  of  function  of  the  joint  is  almost  inevitable.  In  fact,  an 
effort  to  preserve  motion  in  such  a  joint  is  of  doubtful  propriety,  since 
the  disease  is  apt  to  be  exaggerated  if  complete  fixation  is  not  secured 
and  maintained.    If  an  opening  is  not  made  into  the  capsule  it  ultimately 


364 


A  TEXT-BOOK   ON   SURGERY. 


ruptures,  and  a  sinus  gives  exit  to  the  products  of  inflammation.  Opera- 
tive interference  is  usually  indicated  as  soon  as  erosion  of  the  articular 
surfaces  can  be  made  out,  or  as  soon  as  the  symptoms  point  to  the  com- 
munication of  a  focus  of  ostitis  with  the  cavity  of  the  joint.  The  recog- 
nized methods  of  procedure  may  be  given  as  follovrs :  (1)  Fixation  of 
the  joint  without  drainage  ;  (2)  fixation  with  drainage  ;  (3)  opening  into 
the  joint,  with  removal  of  the  diseased  tissues— exsection  or  gouging. 

The  first  method  is  of  the  most  conservative  character,  and  is  only 
justifiable  in  the  mUder  class  of  cases,  where  pain  is  not  severe,  and 
where  sepsis  is  practically  absent.  If  the  leg  can  be  brought  into  the 
straight  position  it  should  be  enveloped  in  a  plaster-of-Paris  cast,  and 
allowed  to  remain  motionless  for  six  or  twelve  weeks,  if  no  urgent 
symptoms  appear.  The  dressing  should  then  be  removed  for  inspec- 
tion, and  reapplied.  This  may  be  continued  until  a  cure  results,  with 
anchylosis. 

If,  on  account  of  subluxation,  the  straight  position  can  not  be  secured, 
extension  in  two  directions  (Fig.  389)  should  be  practiced  until  the  sub- 


FiG.  389.— (After  Sayre.) 


luxation  is  reduced,  or  until  it  is  demonstrated  that  this  can  not  be  done 
without  operation. 

When  the  condition  of  the  joint  demands  drainage  the  same  method 
of  fixation  may  be  practiced,  adding  only  one  or  more  windows  for  out- 
lets to  the  drainage-tubes. 

Operative  invasion  of  the  joint  may  consist  either  of  removal  of  the 
ends  of  the  bones  by  the  saw  or  gouge.  The  former  is  the  prefer- 
able operation,  and  is  now  no  longer  the  formidable  and  complicated 
method  of  a  few  years  back.  Carefully  and  properly  performed,  it  is, 
in  my  opinion,  to  be  ranked  with  the  conservative  operations  at  the 
knee,  and  is  entitled  to  a  consideration  in  the  earliest  stages  of  osteo- 
arthritis. 

Diseases  of  the  Ankle-Joint. — The  pathology,  causes,  and  symptoms 
of  disease  at  the  ankle  do  not  differ  from  those  at  the  articulation  just 
considered. 

Synovitis  is  oftener  traumatic  than  idiopathic.  The  exposed  position 
of  this  articulation,  which  is  called  upon  not  only  to  sustain  the  entire 
body- weight,  but  is  also  frequently  subjected  to  great  lateral  strain,  ren- 
ders it  exceedingly  liable  to  injury. 


DISEASES   OF   SPECIAL   JOINTS.  365 

The  symptoms  of  acute  traumatic  synovitis  at  the  ankle  are  usually 
not  obscure.  Swelling,  pain,  and  heat,  following  prolonged  or  violent 
exertion,  a  twist,  sprain,  or  other  injury,  bear  strong  evidence  of  inflam- 
mation within  the  joint. 

The  injury  most  difficult  to  differentiate  from  intra- articular  synovitis, 
and  one  which  frequently  complicates  synovitis  here,  is  inflammation  of 
the  sheaths  of  the  tendons  which  play  around  the  joint.  The  evidence 
of  thecitis  is  pain  in  the  track  of  the  tendon,  either  elicited  by  direct 
pressure  or  by  j)lacing  the  foot  slowly  in  a  position  which  will  cause  the 
greatest  tension  of  the  tendons,  and  then  requiring  the  patient  to  move 
the  foot  in  various  directions  which  are  resisted  by  the  operator.  To 
test  the  peronei  muscles,  carry  the  foot  well  inward,  hold  it  firmly,  and 
ask  the  patient  to  turn  the  foot  out.  Thecitis  in  the  track  of  these 
tendons  will  arrest  the  effort  at  abduction  and  outward  rotation.  The 
reverse  of  this  manoeuvre  will  serve  to  demonstrate  a  similar  condition  in 
the  flexors  and  internal  rotators. 

Idiopathic  synovitis  of  the  ankle-joint  is  less  painful  and  comes  on 
slowly.  Synovitis  from  exposure  to  cold,  gout,  or  rheumatism  is  fre- 
quently symmetrical,  attacking  either  both  ankles  at  the  same  time,  or 
first  one  and  then  the  other.  Traumatic  synovitis,  on  the  other  hand,  is 
almost  always  unilateral. 

The  prognosis  of  simple  synovitis  of  the  ankle,  when  proper,  vigor- 
ous, and  prompt  treatment  is  instituted,  is  in  general  favorable.  If  left 
alone  it  frequently  ends  in  anchylosis  or  destructive  osteo-arthritis. 

Treatment.  — Acute  synovitis,  whether  of  traumatic  or  idiopathic  ori- 
gin, demands  rest,  with  an  elevated  position  of  the  foot.  Simple  cases 
will  require  no  more  than  this,  with  hot  or  cold  applications,  or  lead-and- 
opium  wash,  applied  by  soft  cloths  laid  loosely  around  the  ankle,  or 
blotting-paper  kept  wet  with  vinegar.  The  employment  of  compression 
will  depend  upon  the  sense  of  relief  it  may  give  the  patient.  Absorbent 
cotton  or  soft  sponges  may  be  used,  applied  carefully  with  a  flannel  or 
muslin  roller. 

Aspiration  of  the  joint  to  relieve  extreme  tension  from  effusion  ap- 
plies here  as  in  other  articulations.  The  needle  should  be  entered  in 
front,  between  the  anterior  margin  of  the  external  malleolus  and  the  con- 
tiguous surface  of  the  tibia,  away  from  the  vessels  and  nerves  which  are 
opposite  the  middle  of  the  joint. 

In  subacute  or  chronic  synovitis,  compression  is  always  indicated,  and 
will  often  cause  absorption  of  the  excessive  efl'usion  in  the  joint.  It  is 
especially  demanded  after  aspiration,  to  give  support  to  the  parts,  and 
to  prevent  a  further  effusion. 

Extension  is  indicated  when  its  employment  gives  relief  from  pain, 
which  rest  and  fixation  without  extension  do  not  aft'ord.  Fixation  with 
liquid  glass  or  plaster  of  Paris  secures  rest  to  the  joint  in  most  cases,  and 
permits  of  locomotion  on  crutches. 

Arthritis  of  the  ankle  is  often  due  to  ostitis  of  the  tibia  or  the 
astragalus. 

The  symptoms  are  those  of  ostitis,  elsewhere  given,  and  the  diagnosis 


366  A  TEXT-BOOK   OX   SURGERY. 

and  prognosis  do  not  differ  materially  from  similar  lesions  in  other 
articulations. 

\YlLeu  osteo-artlu'itis  is  evident,  opeititire  interference  is  indicated,  for 
tlie  reasons  that  (1)  early  incision,  by  giving  discliarge  to  the  contents  of 
tlie  capsule,  retards  or  arrests  the  desti'iictive  process :  (2)  the  common 
experience  of  stu'geons  is  that  the  invasion  of  this  joint  is  practically 
without  danger  to  the  patient's  life. 

Complete  exsection  of  the  articular  ends  of  the  tibia  and  fibula,  and 
of  the  upper  half  of  the  astrag-alus.  is  rarely  called  for.  An  incision 
upon  the  side  which,  fi'om  the  symptoms  present,  will  give  the  best 
access  to  the  diseased  bone,  and  the  free  use  of  Yolkmann's  spoon  or  the 
scalloped  gouge  (page  36)  in  removing  the  dead  tissues,  will  usually 
sufiice.  A  counter-ojieniag  should  be  made,  so  that  thorough  drainage 
by  means  of  the  rubber  tube  may  be  maintaiaed.  The  foot  should  be 
kept  at  rest,  and  the  patient  directed  to  go  on  crutches  until  several 
months  after  the  discharge  has  ceased,  and  the  sinus  closed.  The  oper- 
ation of  gouging  is  more  successful  in  osteo-arthritis  at  the  ankle  than 
in  any  other  articulation.  Complete  exsection  is  only  admissible  when 
the  destruction  is  very  extensive. 

Synovitis  and  osteo-arthritis  of  the  articulations  of  the  tarsus  and 
metatarsus  are  treated  upon  the  same  general  principles  as  just  given  for 
the  ankle. 

The  Shoidder-JoiJif. — Synovitis  of  the  shoulder  is  usually  general: 
in  i-ai'e  instances  it  may  be  local.  It  may  affect  the  general  synovial 
surface  of  the  capsule,  be  reflected  into  the  synovial  sheath  of  the  long- 
head of  the  biceps,  the  bursa  under  the  tendon  of  the  stibscapularis,  or 
that  beneath  the  inira-spinatus.  or  in  rare  instances,  especially  in  the 
earlier  stages,  one  or  more  of  these  bursse  may  be  inflamed,  while  the 
joint  is  not  invaded.  The  biu-sa  between  the  deltoid  and  the  capsule 
may  also  be  the  seat  of  bursitis,  although  this  sac  does  not  communicate 
with  the  joint.  The  diagnosis  of  inflammation  in  one  or  more  of  the 
bursie  about  the  shotilder  may  be  determined  as  follows  :  1.  Direct  digi- 
tal pressiu'e  upion  any  single  bursa  will  indicate  the  sensibility  of  the 
part.  2.  Extend  the  forearm  fully,  grasp  the  hand  and  elbow  of  the 
patient,  and,  while  the  head  of  the  humerus  is  pulled  away  from  the 
glenoid  cavit\%  direct  the  patient  to  make  strong  flexion,  which  the 
operator  firmly  resists.  If  inflammation  of  the  sheath  of  the  long  head 
of  the  biceps  exists,  pain  will  be  exi^erienced  in  the  anterior  and  outer 
portion  of  the  joint  as  this  tendon  is  made  tense.  3.  TYhen  the  bursa 
tinder  the  infr-a-spinanis  is  inflamed,  if  the  arm  is  rotated  inward,  and 
held  in  this  position,  pain  wiU  be  felt  when  the  tendon  of  this  muscle 
is  made  to  p^ress  sti-ongly  on  the  biu'sa,  in  any  effort  at  outward  rotation. 

An  opposite  mana?tivre  will  serve  as  a  test  for  the  bursa  beneath  the 
tendon  of  the  subscaptilaiis.  In  general  si/nocifis  each  of  these  move- 
ments wUl  be  productive  of  p^ain,  and  the  differentiation  is  chiefly  between 
neuralgia  and  muscular  rhetimatism.  In  neuralgia  the  pain  is  of  the 
peculiar  neuralgic  type.  It  is  rarely  constant,  the  exacerbation  appear- 
ing at  intervals  of  compai-ative  regularity,  and  extending  in  the  recog- 


DISEASES  OF   SPECIAL   JOINTS.  367 

nized  course  of  the  nerres.  Motion  is  not  painful  in  the  degree  which 
characterizes  either  synovitis  or  rheumatLsm,  and,  if  jjersisted  in,  the  sense 
of  X'ain  may  entirely  disajjpear.  Pressure  upon  the  nerves,  which  lead 
to  and  beyond  the  articulation,  will  at  times  cause  jjain  similar  to  those 
felt  in  neuralgia  of  the  joint.  Swelling  is  not  a  feature  of  a  neurosis. 
In  rheumatisTn  of  the  muscles  about  the  joint  the  jiain  is  superficial,  and 
may  be  elicited  by  digital  jjressure  upon  the  substance  of  the  muscles. 
In  rheumatLsm  redness  is  more  apt  to  be  jjresent,  and  the  area  of  swell- 
ing extends  farther  than  in  synovitis. 

The  treatment  of  synovitis  is  the  same  at  all  joints.  Artificial  exten- 
sion is  rarely  needed,  since  the  weight  of  the  extremity  is  sufficient. 

Aspiration  is  a  safe  and  efiicient  means  of  relief  from  jjain,  and  is 
indicated  when  there  is  marked  capsular  tension.  The  needle  should  be 
entered  through  the  center  of  the  joint  in  front.  Fixation  of  the  joint 
by  a  .shoulder-cap  of  felt,  card-board,  or  leather,  should  be  secured  im- 
mediately after  aspiration  ("page  297j.  ^Yhen  ready  for  ajjplication,  lay 
upon  the  surface  of  the  board  which  is  to  be  nearest  the  skin  a  layer 
of  absorbent  cotton,  which  shall  be  wide  enough  to  extend  entirely 
around  the  arm  and  over  the  shoulder,  place  it  in  position,  and  se- 
cure snugly  bv  a  tigure-of-8  bandage  around  the  arm  and  shoidder  (see 
Fig.  IT;. 

Acute  suppurative  synovitis  demands  an  immediate  evacuation  of  the 
purulent  contents  of  the  caj^sule  by  means  of  the  asjjirator,  and,  if  the 
joint  refills  rajjidly,  and  the  pain  and  temperature  continue  or  are  exag- 
gerated, it  should  be  ojjened  and  thoroughly  cleansed  and  drained.  The 
incision  is  the  same  as  for  excision  of  the  head  of  the  humerus,  namely, 
from  the  anterior  internal  tip  of  the  acromion,  parallel  with  the  fibers  of 
the  deltoid  along  the  anterior  margin  of  the  great  external  tuberosity. 
The  capsule  is  opened  external  to  the  long  head  of  the  bicejjs,  and,  while 
traction  is  firmly  made  upon  the  edges,  the  cavity  may  be  thoroughly 
explored  and  cleansed.  It  is  of  vital  importance  that  in  this,  as  in  every 
cavity  which  is  the  seat  of  purulent  inflammation,  drainage  should,  when 
pos.sible,  be  established  from  that  jjortion  of  the  wound  which  is  most 
dependent.  As  the  jjadent  rests  in  bed  the  jjosterior  and  outer  jjart  of 
the  capsule  is  lowest.  A  dull-pointed  dressing-forceijs  should  be  car- 
ried into  the  cafjsule  through  the  anterior  incision  and  bored  through 
the  inferior  jjosterior  wall  and  all  the  tissues  to  the  skin,  and  when  this 
is  pushed  ahead  of  the  instrument  an  incision  .should  be  made  to  allow 
the  escafje  of  the  instrument.  The  wound  is  stretched  by  oijening  the 
jaws  of  the  instrument,  and  a  rubljer  tube  X-mlled  into  x^lace  as  the  in- 
strument is  withdr-awn.  In  osteo-arthritis  of  the  shoulder- joint  ex.section 
is  demanded. 

The  Elhow-JrAnt. — Synovitis  of  this  articulation  need  not  be  sepa- 
rately considered.  The  .same  general  jjrinciples  of  diagnosis  and  treat- 
ment apply  here  as  in  other  joints.  Destructive  osteo-arthritis  demands 
gouging  or  exsection.     The  operation  \vill  be  given  hereafter. 

TTte  Wrist-Joint. — Inflammation  of  the  synovial  membranes  of  the 
wrist  or  in  the  immediate  neighborhood  of  this  joint  is  of  frequent  occur- 


368 


A  TEXT-BOOK   OX   SOIGERT. 


rence.  It  is  usTjally  traumatic  in  origin,  occasionally  idiopatMc.  It  may 
attack  the  synovial  sac  betvreen  the  nlna  and  radins  :  that  between  the 
radius  and  the  fibro-cartilage  and  the  lirst  carpal  row :  the  general  syno- 
vial sac  benveen  the  first  and  second  rows  and  the  metacarpus  :  or  that 
between  the  base  of  the  first  metacarpal  bone  and  the  trapezius  '  Fig.  390 ». 
Inflammation  of  the  sheaths  of  the  tendons  on  the  dorsum  of  the  carpus 
or  on  the  palmar  surface  may  also  complicate  a  carpal  synovitis,  or  exist 
alone.  The  contigoity  of  these  various  structures  renders  a  positive  diag- 
nosis of  great  difficulty.  If.  when  the  bones  of  the  forearm  are  grasped 
near  their  center  and  pressed  together,  sharp  pain  is  elicited  at  the  wrist, 
synovitis  of  the  radio-carpal  sac  is 
indicated.  When  the  swelling  is 
well  defined  at  the  edge  of  the  ar- 
ticular end  of  the  radius,  extends 
across  the  wrist,  and  is  limited  to 
the  situation  of  the  first  row  of  the 
carpus,  the  radio-carpal  sac  is  prob- 
ably alone  involved.  W  hen  the 
several  capsules  are  involved  the 
swelling  is  general  In  thecitis 
the  pain  is  superficial,  and  usual- 
ly extends  for  some  distance  along 
the  tendons  above  and  below  the 
joint.  Contraction  of  the  mus- 
cles, the  tendons  of  which  are  in- 
volved, will  point  to  the  location  of 
the  inflammation.  Differentiation 
of  synovitis  from  Colles's  fracture 

will  depend  upon  a  study  of  the  symptoms  of  this  lesion  already  given. 
Osteo-arthritis  in  its  earlier  stages  is  comparatively  a  painless  process, 
and  even  after  the  capstile  is  invaded  is  rarely  as  painful  as  an  acute 
synovitis. 

Treatment. — Synovitis  of  the  wrist  does  not  demand  separate  con- 
sideration. Destructive  osteo-arthritis  reqtiires  gouging  or  exsection. 
Synovitis  of  the  metacarpal  or  interphalangeal  joints  should  be  treated 
on  general  principles  of  rest  and  fixation. 


/ 


Fig.  -590.— {After  Gray.) 


EXSZCTIOXS   OF  THE  JOETTS. 

TTie  Hip — Bay  res  Operation.— V]ace  the  patient  on  the  sound  side : 
carry  the  point  of  a  strong  scalpel  perpendicularly  down  to  the  bone 
exactly  half-way  between  the  anterior-superior  spine  of  the  iUum  and 
the  tip  of  the  trochanter  major :  *  cut  along  the  neck  of  the  femur, 
keeping  the  knife  firmly  in  contact  with  the  bone,   carrying  the  in- 

*  The  estremitr  should  be  held  parallel  with  the  asis  of  the  spine,  with  the  foot  normally 
rotated  outward. 


EXSECTIOXS   OF   THE  JOINTS. 


369 


cision  midway  between  tlie  center  and  posterior  aspect  of  the  trochan- 
ter, and  then  curring  it  slightly  forward  as  it  passes  about  an  inch 
below  the  tuberosity  (Fig.  391).  Throngh  this  incision,  which  divides 
the  capsule  and  thickened  periosteum,  insert  the  elevator  and  lift  the 
periosteal  investment  from  the  diseased  bone.  When  the  trochanters  are 
involved,  the  tendons,  inserted  into  these  eminences  and  into  the  digital 

fossa  just  above  the  great  tuberosity,  usu- 
ally require  to  be  detached  ^vith  the  knife, 
the  point  of  which,  in  order  to  avoid  wound- 
ing any  vessels,  should  be  kept  in  close  con- 
tact with  tlie  bone.  As  soon  as  the  perios- 
teum is  freely  raised,  the  bone  should  be 
t    ,,  \  N     a      divided,  preferably  -with  the  exsector  (Fig. 

[-/  ''^    I     79),   and  the  upper  fragment  lifted   out 

with,  the  elevator.  If  the  exsector  is  not 
used,  the  chain-  or  key-hole  saw  or  cutting- 
forceps  may  be  employed.  The  sawn  sur- 
face shonld  be  carefuUy  inspected  in  order 
to  see  if  the  disease  extends  farther  down 
the  bone,  necessitating  a  second  division. 
The  acetabulum  should  next  be  examined, 
thoroughly  scraped  with  a  Volkmann's 
spoon,  and  all  dead  tissue  removed.  Heem- 
orrhage  is  usually  insignificant,  and,  if 
occurring,  should  be  arrested  as  the  oi:)er- 
ation  progresses.  The  wound  should  be 
thoroughly  inigated  with.  l-to-3C>00  subli- 
mate, all  shreds  of  tissue  and  particles  of 
bone  removed,  and  the  entire  cavity  filled 
with  sublimate  gauze,  well  packed  iU;  and 
held  in  place  by  a  thigh  and  pelvic  spica. 
Pig.  391.  The  patient  should  now  be  put  to  bed  with 

an  extension  apparatus  applied  as  given 
for  the  early  treatment  of  hip-disease.  Sand-bags  may  be  laid  along 
the  leg  to  hold  the  foot  in  the  proper  degree  of  outward  rotation,  or  a 
splint  may  be  used.  The  long  splint  from  the  axilla  to  the  heel  is  often 
required  to  prevent  a  child  from  sitting  upright  in  bed.  The  first  dress- 
ing is  changed  usually  about  one  week  after  the  operation,  and  once 
or  twice  a  week  thereafter.  After  four  or  five  weeks  the  combination 
mietJiod  shotdd  be  employed,  and  the  case  treated  as  in  the  first  stage. 
Prof.  Sayre  prefers,  and  frequently  employs,  the  wire  breeches  for  the 
first  few  weeks  after  the  operation.  This  instrument  cau  not  always 
be  obtained,  and  the  extension  in  bed  h.as  proved  perfectly  satisfac- 
tory. 

In  a  certain  proportion  of  cases  the  disease  is  not  arrested  by  the  first 
operation,  and  a  second  is  required. 

The  outline  of  the  parts  involved  in  this  operation  is  weU  shown  in 
Fig.  392. 

•24 


370 


A  TEXT-BOOK   ON  SURGERY. 


Fig.  392. — 1,  Ligaraentum  t^res.  2,  External 
obturator  muscle  and  obturatdr  vessels. 
3,  Circumflex  vessels,  i,  Conjoined  ten- 
don of  psoas  and  iliaous.     (After  Braune.) 


Operation. — Shave  the  parts  thor- 
oughly, including  portions  of  the 
thigh  and  leg,  ten  inches  above  and 
below  the  articulation  and  wash  with 
soap  and  brush,  then  ether,  and  last- 
ly 1-1000  sublimate  solution.  Ele- 
vate the  foot  in  order  to  empty  the 
extremity  of  blood,  and  after  a  min- 
ute or  two  apply  the  rubber  tube 
tourniquet  at  the  middle  of  the  thigh. 
With  the  leg  straightened  out,  or 
slightly  flexed  (Fig.  393),  an  incision 
is  made  across  the  center  of  the  pa- 
tella and  down  on  each  side  until  the 
level  of  the  posterior  surface  of  the 
tibia  is  reached.  These  points  must 
be  low  in  order  to  secure  free  drain- 
age. The  skin-flaps  or  cuffs  are  now 
dissected  and  rolled  up  until  the  up- 
per one  is  turned  back  from  two  to 
three  inches,  the  lower  about  one  and 
a  half  inch.  As  the  flaps  are  held 
well  away  by  assistants,  the  operator 
cuts  down  to  the  femur  through  the 
tissues,  parallel  with  the  attached  edge  of  the  reflected  upper  flap,  lift- 
ing everything  from  the  anterior  aspect 
of  the  femur  and  its  condyles  together 
with  the  patella,  the  attached  fringes, 
ligamentum  patellse  and  coronary  liga- 
ments— thus  clearing  in  one  mass  all  the 
tissues  which  envelop  the  anterior  three- 
fourths  of  the  joint. 

By  sharply  bending  the  knee  the  cru- 
cial ligaments  are  exposed  and  divided, 
the  lateral  ligaments  cut  away,  and  the 
disarticulation  effected.  In  stripping 
the  attachments  of  the  ligamentum  pos- 
ticum  Winslowii  from  the  tibia  and  fe- 
mur, the  operator  should  closely  hug 
the  bone  and  thus  avoid  wounding  the 
vessels.  This  dissection  should  extend 
about  three-fourths  of  an  inch  below  the 
level  of  the  tibia  and  one  and  a  half 
inch  above  the  lowest  siarface  of  the 
condyles.  Determining  now  the  amount 
of  bone  necessary  to  be  removed,  a  cloth 
retractor  is  applied  so  as  to  protect  the 
soft  parts  from  bone  detritus  or  injury, 


EXSECTIONS   OF   THE   JOINTS.  371 

and  a  slice  thick  enougli  to  freshen  the  head  of  the  tibia  is  sawed  away, 
as  nearly  as  possible  parallel  with  the  normal  plane  of  the  articular  sur- 


FiG.  391. — Longitudinal  section  thiioiyh  the  knet  i  mt     1,  Peroneal  nerve.    2,  Popliteal  vessels. 
( After  Braune  ) 


372 


A  TEXT-BOOK   ON   SURGERY. 


faces.  Should  the  section  expose  a  focus  of  disease  which  dips  down 
into  the  bone,  this  should  be  cleared  out  with  a  scoop  or  Yolkmann's 
spoon,  and  finally  mopped  with  a  strong  bichloride  solution  (1  to  500). 
It  is  important,  and  especially  in  children  and  yonng  adults,  that  the 
section  should  not  involve  the  epiphyseal  lines. 

The  section  through  the  end  of  the  femur  should  now  be  made  (Fig. 
394).  It  follows  that  if  the  limb  is  to  be  straight  in  the  position  of 
anchylosis,  the  sawed  surfaces  of  the  two  bones 
must  be  parallel.  I  have  found  it  of  great  value  to 
employ  this  method.  By  pulling  on  the  foot  the 
limb  is  fully  straightened,  and  the  articular  sur- 
face of  the  femur  separated  from  the  sawed  surface 
of  the  tibia.  If  the  operator  will  now  start  the  saw 
into  the  femur,  sighting  by  the  flat  face  of  the 
tibia,  the  instrument  will  cut  directly  parallel  with 
this.  If  by  error  the  section  of  the  tibia  has  been 
slightly  oblique,  that  of  the  femur  will  have  a  like 
obliquity,  and  therefore  the  bones  will  tit  snugly 
with  the  extremity  straight. 

The  next  step  is  to  dissect  away  with  forceps 
and  curved  blunt  scissors  all  the  diseased  capsule. 
This  should  be  done  thoroughly,  and  even  the 
bursse  that  communicate  with  the  joint  should  be 
cleaned  out.  If  care  is  not  taken,  a  portion  of  the 
sac  which  extends  up  beneath  the  quadriceps  ten- 
don will  not  be  removed.  All  bleeding  points 
should  be  tied  with  catgut  and  all  hsemorrhage 
stopped.  The  bones  are  now  brought  in  exact  ap- 
position, and  while  so  held  the  steel  drills  (Fig. 
395)  are  introduced.     I  usually  carry  two  of  these 


in  from  below  upward,  passing  them  through  the 

skin  about  two  inches  below  the  sawn  surface  of 

the  tibia  and   directing   them   obliquely  through 

the  tibia  into   the  femur.     When  the  end  of  the 

drill  has   reached   the   compact  substance  of  the 

femur,  it  is  stopped,  the  handle  unshipped,  and  the 

drill  left  in  position.     Three  are  used,  one  on  either 

side  from  below,  and  one  directly  down  the  median 

line  from  above,  entering  the  femur  and  passing 

into  the  tibia  (Fig.  397). 

As  the  leg  is  now  held  steady  the  edges  of  the  wound  in  the  skin  are 

sewed  together  with  catgut,  and  two  short  bone  drains  inserted  at  the 

inferior  angle.     I  no  longer  use  rubber  drains,  having  had  considerable 


with    ad- 


FiG.  396, 
Wyeth's    drill;  , 

justable  handle,  for  fix- 
ation of  the  bones  in 
knee-joint  exseotion. 


EXSECTIONS   OF  THE   JOINTS. 


373 


trouble  with  the  sinuses  that  persist  after  their  removal.  If  the  absorb- 
able bone  drain  is  not  at  hand,  twists  of  catgut  will  suffice.  The  united 
lips  of  the  wound  are  dusted 
with  iodoform,  a  narrow  strip  of 
aseptic  protective,  split  so  as  to 
fit  over  and  not  obstruct  the 
drainage-tubes,  lies  over  the  sut- 
ures, and  over  this  a  light  layer 
of  iodoform  gauze  and  then  suc- 
cessive layers  of  sublimate  gauze, 
until  the  whole  limb  from  the 
ankle  to  the  hip  is  invested  to 
the  thickness  of  about  two  inch- 
es. One  thickness  of  absorbent 
cotton  is  now  applied,  and  on  the 
top  of  this  successive  layers  of 
veneering  or  thin  wooden  splints 
are  applied  under  firm  com- 
pression of  a  roller.  Over  all, 
one  layer  of  starched  crinoline 
bandage  is  placed.  This  dress- 
ing is  allowed  to  remain  on  for 
from  two  to  three  weeks,  and 
when  changed  at  this  time  the 
drills  are  pulled  out. 

The  roller  should  be  firmly 
drawn,  so  that  a  considerable 
pressure  may  be  exercised  upon 
the  part,  to  prevent  oozing.  The 
elasticity  of  the  cotton  distrib- 
utes the  pressure  equally,  and 
controls  haemorrhage  without 
causing    discomfort.      It    is    the 

practice  of  some  surgeons  not  to  apply  a  single  ligature  in  this  opera- 
tion, but  to  rely  wholly  upon  compression  for  the  control  of  bleeding, 


Fig.  397. — Shoiring  fixation  of  bones  bv  the  drills. 
Wound  closed  with  catgut  sutures.  £,  Absorbable 
bone-drain  of  one  side.     i>,  Fixation  drills. 


374 


A  TEXT-BOOK   ON  SURGERY. 


It  is  better  to  search  for  and  tie  the  larger  vessels  which  may  have 
been  divided.  As  in  all  the  antiseptic  operations,  the  indications  for  a 
change  of  dressing  are  haemorrhage,  high  temperatures,  and  decompo- 
sition of  the  discharge  beyond  the  zone  of  asepsis.  AVhen  the  wound 
is  dressed,  careful  antisepsis  shoixld  be  practiced.  Recovery,  with  an- 
chylosis in  the  straight  position,  is  the  result.  No  effort  at  passive 
motion  should  be  entertained.  This  operation  has  met  with  remarkable 
success  within  late  years.  The  drills  are  preferable  to  nails  in  fixation. 
They  are  carried  into  position  by  steady  pressure  on  the  handle,  with 
a  slight  half  rotary  movement.  When  they  can  not  be  obtained,  the 
parts  may  be  held  in  apposition  by  wiring  the  bones  together  and  ap- 
plying an  interrupted  plaster-of -Paris  dressing,  as  shown  in  Fig.  397  a. 

The  Ankle-joint. — For  the  complete  exsection  of  the  articular  ends 
of  the  tibia  and  fibula  and  the  astragalus,  proceed  as  follows :  Commence 
an  incision  on  the  internal  surface  of  the  tibia,  about  two  inches  above 


the  tip  of  the  inner  malleolus,  and  carry  it  directly  down  to  this  point, 
and  thence  directly  forward,  from  one  inch  to  one  inch  and  a  half  along 
the  tarsus,  in  the  direction  of  the  metatarsal  bone  of  the  great  toe  (Fig. 
398).  A  like  L-shaped  incision  is  made  upon  the  fibular  side  of  the  Joint 
(Fig.  399).    These  incisions  divide  all  the  tissues  down  to  the  bone.    With 


Fig.  400. — Volkmann's  anterior  splmt. 


the  Sayre  elevator  lift  the  periosteum,  with  its  attachments  to  the  super- 
jacent soft  tissues  undisturbed,  from  the  diseased  portions  of  bone.  Ex- 
pose the  outer  malleolus  and  fibula  as  high  as  it  is  deemed  necessary  to 
remove  this  bone,  and  divide  it  with  the  exsector  (or  chisel).  As  soon  as 
the  piece  is  removed  the  Joint  is  thoroughly  exposed  to  view.     Now, 


EXSECTIONS   OF   THE   JOINTS. 


375 


further  lift  the  periosteum  of  the  tibia  and  tarsus,  and,  by  forcibly  bend- 
ing the  foot  inward,  dislocate  the  tibia  and  inner  malleolus  outward, 
through  the  wound  on  the  fibular  side.  The  diseased  surface  may  be 
sawn  off  with  an  ordinary  saw,  or  with  the  exsector.  The  section  through 
the  astragalus  may  be  made  with  a  gouge,  chisel,  or  a  key-hole  saw. 


Usually  no  vessels  of  importance  are  wounded  in  this  dissection,  since. 
by  keeping  beneath  the  periosteum,  they  are  lifted  with  the  tissues.  The 
periosteum  should  not  be  elevated  over  the  healthy  bone.  The  sawn 
surfaces  are  now  brought  in  apposition,  so  that  the  foot  will  be  at  an 
angle  of  90°  with  the  axis  of  the  leg.     Fixation  may  be  secured  by  trans- 


576 


A  TEXT-BOOK   ON   SURGERY. 


402. — The  foot  after  exsection  of  the  astrt 
and  articular  ends  of  tibia  and  fibula. 


fixion  with  small  steel  drills,  carried  obliquely  from  above  downward, 
entering  on  the  internal  aspect  of  the  tibia  and  the  external  surface  of 
the  fibula,  and  passing  into  the  astragalus  (in  the  same  manner  as  at  the 
knee).  The  wound  shoiild  be  closed  with  catgut,  leaving  a  small  absorb- 
able bone  drainage-tube  to  pass  out  on  each  side.  An  antiseptic  dress- 
ing is  now  applied,  and  the  foot  and  leg  placed  in  a  fracture-box  and 
padded  to  hold  it  motionless. 

If  the  drills  are  not  employed,  the  parts  should  be  held  in  apposition 
while  a  plaster  -  of  -  Paris  dressing  is  applied,  which,  being  "set," 
is  fenestrated  on  both  sides  over  the  wounds,  in  the  same  manner 
as  shown  in  Fig.  350.  Or  a  Volkmann's  splint  (Fig.  400}  may  be 
applied  to  the  anterior  extremity 
of  the  foot  and  leg,  and  the  parts 
fixed  with  plaster  of  Paris,  or  sim- 
ple roller.  This  splint  may  be 
made  of  wood,  or  sheet-  or  hoop- 
iron,  properly  padded  with  anti- 
septic gauze.  A  useful  substitute 
may  be  made  from  several  pieces 
of  telegraph-wire. 

If  the  bones  are  not  extensively 
involved,  a  single  L'-shaped  incision 
will  suffice  to  expose  the  joint,  and 
the  dead  bone  can  be  removed  with  the  gouge  or  Volkmann's  sj^oon,  and 
a  counter-opening  made  for  drainage.  This  operation  is  always  to  be 
preferred  at  the  ankle. 

When,  in  an  exsection  of  the  ankle,  the 
astragalus  is  so  much  involved  that  its  re- 
moval is  necessary,  the  upper  surface  of  the 
OS  calcis  should  be  smoothed  off  with  the 
chisel  or  key- hole  saw,  and  brought  up  in 
apposition  with  the  plane  surface  of  the 
bones  of  the  leg.  Fig.  402  represents  a  foot 
after  recovery  upon  which  I  did  this  opera- 
tion in  1885. 

The  Shoulder -Joint. — Exsection  of  the 
head  of  the  humerus  is  readily  effected  by 
a  single  straight  incision,  about  five  inches 
in  length,  made  from  the  acromion  process 
dii-ectly  down  the  arm,  parallel  with  and 
splitting  the  fibers  of  the  deltoid  (Fig.  403). 
The  periosteum  should  be  carefully  lifted  as 
far  as  the  ostitis  extends,  and  the  soft  tis- 
sues about  the  capsule  raised  with  the  ele- 
vatoi\  The  edges  of  the  wound  should  be 
held  wide  apart  by  blunt  retractors,  and  the 
tendons  of  insertion  of  the  supra  and  infra 
spinatus,  teres  minor,  and  subscapularis  di- 


EXSECTIONS   OF   THE   JOIXTS. 


377 


Fig.  404. — Loneitudinal  section  tbrough  the  shoulder-joint, 
showing  the  relations  of  the  bones,  ligaments,  and  mus- 
cles immediately  about  the  articulation.  1,  The  capsu- 
lar ligament.  2,  The  acromion.  3,  Epiphysis.  (Alter 
Braune.) 


vided  close  to  the  tuberosities  with  the  curved  blunt  scissors.  The  sheath 
for  the  long  head  of  the  biceps  should  be  laid  open,  and  this  tendon  held 
aside.  If  the  exsector  is  used,  the  bone  should  now  be  divided  at  the 
limit  of  the  disease.     When  the  section  is  completed  a  strong  hook 

should  be  fastened  into  the 
end  of  the  upper  fragment, 
in  order  to  lift  it  and  facili- 
tate the  separation  of  the  soft 
tissues  on  the  inner  and  un- 
der surface  from  the  bone  and 
capsule.  The  capsular  liga- 
ment should  be  trimmed  from 
the  margins  of  the  glenoid 
cavity  and  removed  with  the 
head  of  the  humei'us.  All 
diseased  tissues  should  be 
dissected  out  vrith  the  curved 
scissors,  and,  if  the  head  of 
the  scapula  is  involved,  all 
disorganized  bone  should  be 
scraped  away  with  the  spoon 
or  rongeur.  If  the  exsector  can  not  be  had,  the  capsule  should  be  di- 
vided and  the  head  of  the  bone  dislocated  upward  through  the  wound. 
The  division  is  then  made  with  a  narrow  saw,  taking  the  precaution  to 
protect  the  soft  parts  from  injiiry.  Upon  examining  the  wound  left 
after  this  operation,  it  will  be  seen  that  the  deepest  portion  is  behind  and 
to  the  outer  side  of  the  end  of  the  shaft.  Into  this  depression  carry  a 
closed  di'essing-forceps,  and  bore  through  to  the  skin,  pointing  the  in- 
strument to  the  inferior  and  outer  aspect  of  the  arm.  Divide  the  skin 
over  the  point  of  the  forceps,  dilate  the  opening  by  separation  of  the 
handles,  and  draw  a  drainage-tube  from  below  upward  through  the  hole. 
A  second  shorter  tube  should  make  its  exit  through  the  anterior  and 
lower  angle  of  the  wound  of  incision,  and  the  wound  closed  throughout 
with  catgut.  The  forearm  should  be  held  in  a  sling  or  fastened  across 
the  abdomen.  The  application  of  Esmarch's  bandage,  and  the  rubber 
tubing  in  the  axilla  and  over  the  clavicle  and  scapula,  renders  this  oper- 
ation practically  bloodless.  The  rate  of  mortality  is  exceedingly  low. 
With  careful  antisepsis  it 
is  practically  without  dan- 
ger to  life.  A  second  oper- 
ation for  the  removal  of 
dead  bone  is  occasionally 
required. 

TheUlboto-Jomt.—Fle:si 
the  forearm  on  the  arm  and  fro.  405. 

make  a  straight  incision, 

commencing  in  the  middle  of  the  posterior  aspect  of  the  humerus,  about 
one  inch  above  the  condyles,  and  extending  over  the  center  of  the  olec- 


378 


A  TEXT-BOOK   ON  SURGERY. 


ranon  process,  along  the  ulnar,  for  from  two  to  three  inches  (Fig.  405). 
The  tissues  should  be  carefully  lifted  from  the  bone  and  capsule,  and 
held  to  either  side  by  blunt  retractors.  When  the  trough  between  the 
olecranon  and  internal  condyle  is  approached,  extra  care  should  be  taken 
not  to  wound  the  ulnar  nerve,  which  passes  in  this  groove.  It  may  be 
avoided  by  keeping  close  to  the  bones  with  the  knife  or  elevator.  The 
articular  end  of  the  humerus  should  be  exposed,  as  high  as  the  point  of 
section,  by  peeling  off  the  soft  tissues  with  the  periosteum,  after  which 
a  retractor  is  applied  and  the  bone  divided  at  an  angle  of  90°  to  the  shaft 
of  the  humerus.  The  ends  of  the  ulna  and  radius  may  now  be  readily 
displaced  backward,  exposed  to  the  point  of  section,  and  divided  on  a 
line  parallel  with  that  through  the  humerus.     As  in  all  the  joint  ex- 


Fig.  406. — Longitudinal  section  through  the  elbow-joint.     1,  Eadial  ner-ve.    Superficially  on  the  flexor 
surface  the  median  basilic  vein  is  seen  cut  across.     (Alter  Braune.) 

sections,  a  careful  dissection  of  all  the  diseased  capsule  and  soft  parts 
must  be  made.  The  wound  is  drained  from  the  most  dependent  por- 
tion, and  closed  with  catgut  sutures.  On  account  of  the  sinuses  which 
are  apt  to  persist  after  a  rubber  drain,  it  is  preferable  to  employ  the 
absorbable  bone  drain  of  Neuber  at  the  elbow.  An  anterior  splint, 
previously  fitted  to  the  arm  and  forearm,  and  fashioned  so  as  to  hold 
the  forearm  half-way  between  flexion  at  a  right  angle  and  complete 
extension,  is  wrapped  with  gauze  and  laid  on  the  anterior  aspect  of  the 
extremity,  and  fixed  by  a  roller  to  the  arm  and  forearm,  to  within  a  few 
inches  of  the  incision.  A  sublimate  dressing  is  next  ajiplied  to  the 
wound,  with  cotton  and  protective,  and  a  bandage  over  this  to  effect 
compression  and  to  hold  it  in  position.  When  a  change  of  dressing  is 
required,  this  last  bandage  only  is  removed.  The  rule  in  this  exsection 
is  fibrous  anchylosis,  with  limited  motion  of  the  joint  and  function  of 
the  extremity. 

Exsection  of  the  elbow  is  not  a  dangerous  procedure,  and,  although 
not  usually  attended  with  the  success  which  follows  some  other  opera- 


EXSECTIONS   OF  THE   JOINTS. 


379 


tions  (as  those  upon  the  shoulder  and  ankle),  it  should  be  preferred  to 
amputation.    The  anatomical  relations  at  this  joint  are  shown  in  Fig.  406. 
The  Wrist-Joint. — The  exsection  of  this  joint  is  attended  with  con- 
siderable difficulty,  not  only  m.  the  performance  of  the  operation,  but  in 


Fig.  407. — Bourgery's  operation  (modified). 


Fig.  408. — Langenbccl^'s  mcibion.     (After  Ehmaroli.) 


the  after-treatment.  Moreover,  it  is  more  apt  to  be  followed  by  failure, 
resulting  in  amputation.  Of  the  two  procedures — viz.,  the  double  lateral 
and  parallel  incisions  (Fig.  407),  and  the  single  longitudinal  dorsal  incision 
(Fig.  408) — the  latter  is  preferable  when  the  destructive  process  is  not  so 
extensive,  and  when  the  spoon  or  gouge  may  be  used,  while  the  fonner 
will  give  the  freest  access  to  the  bones  when  the  saw  or  exsector  is  to 


Fig.  409. — Esmareh's  interrupted  splint  for  exsection  of  the  -n-rist. 

be  employed  in  the  removal  of  a  large  portion  of  the  bones  which  enter 
into  the  composition  of  this  joint. 


380 


A  TEXT-BOOK   ON   SURGERY. 


Fig.  410.— TLe  same  applied. 


lu  the  operation  with  a  single  dor- 
sal incision  the  wrist  should  be  made 
prominent,  by  flexing  the  hand  on  the 
foreai-m,  and  the  integument  divided 
along  the  tendon  of  the  extensor  com- 
munis digitorum,  which  goes  to  the 
index -finger,  the  incision  extending 
from  the  middle  of  the  metacarpiis  to 
one  inch  and  a  half  above  the  tip  of 
the  styloid  processes.  The  tendon  may 
be  retracted  to  the  side  most  conven- 
ient. The  posterioi-  segment  of  the  an- 
nular ligament  is  divided,  and  the  tis- 
sues lifted  from  the  bones  with  the 
elevator.  The  end  of  the  radius  should 
be  removed  with  the  exsector  or  gouge, 
when  the  carpus  may  be  displaced 
backward  through  the  incision,  and 
removed  wholly  or  in  pieces.  When 
the  section  is  completed,  the  surfaces 
should  be  brought  in  apposition  and 
fixed  upon  a  well-adjusted  anterior 
splint.  Or  an  interrupted  dressing  may 
be  applied  by  incasing  the  forearm  in 
plaster  of  Paris  to  within  an  inch  of 
the  incision,  and  the  fingers  and  hand 
in  the  same  material,  back  as  far  as 
the  anterior  limit  of  the  wound.  A 
piece  of  hoop-iron  (or  several  jDieces 
of  telegraph-mre  twisted  into  a  single 
piece)  is  shaped  as  shown  in  Pig.  409, 
incorporated  into  the  plaster  upon  the 
arm,  and  made  to  loop  over  the  wrist 
to  the  tips  of  the  fingers,  where  it  is 
turned  back  underneath  the  hand,  and 
is  fastened  to  the  plaster  here  by  an 
additional  gypsum  bandage  (Pig.  410). 

In  the  other  operation  one  incision 


EXSECTIONS   OF  THE   JOINTS.  381 

is  made  along  the  outer  and  dorsal  aspect  of  the  metacarpal  bone  of  the 
little  finger,  over  the  styloid  of  the  ulna,  and  one  inch  along  this  bone. 
The  radial  incision  should  commence  on  the  dorsum  of  the  metacarpal 
bone  of  the  index-finger,  pass  backward  and  slightly  toward  the  radial 
surface  of  the  forearm  to  a  point  half  an  inch  above  the  tip  of  the 
styloid  process,  and  thence  directly  upward  along  the  dorsal  aspect  of 
the  radius.  In  extensive  operations  it  may  become  necessary  to  divide 
the  tendon  of  the  extensor  ossis  metacarpi  pollicis,  which  is  crossed  by 
the  incision.  When  done,  the  ends  should  be  reunited  by  silk  sutures 
when  the  operation  is  finished.  The  tissues  are  lifted  from  the  bones 
and  capsule  as  before,  and  the  sections  made  with  the  exsector  or  key- 
hole saw. 

Metacarpo-Phalangeal  and  Inter-Plialangeal  Joints. — Excision  of 
the  metacarpo-phalangeal,  on  the  inter-j^halangeal  articulations,  may  be 
done  when  the  destruction  of  bone  is  limited.  The  same  general  i-ule, 
viz.,  that  an  excision  is  preferable  to  amputation,  is  applicable  both  to 
the  hand  and  foot.  At  the  tenninal  joints,  however,  the  small  size  of  the 
last  phalanges  will  rarely  permit  of  any  operation  except  amputation. 


CHAPTER  XIV. 

KEGIONAL   SURGERY. — THE   HEAD. 

Tumors  of  the  Scalp. — The  most  common  tumors  of  the  scalp  are 
cysts.     They  are  congenital  and  acquired. 

Congenital  cysts  are  rare  as  compared  with  the  acquired.  They  are 
deeply  situated,  being  beneath  the  skin,  and  not  infrequently  below  the 
fascia  and  muscles.  Their  contents  are  chiefly  white  or  yellow  fluid,  and 
at  times  hairs.  Each  tumor  may  consist  of  a  single  cyst,  or  there  may  be 
several  grouped  together  (multilocular),  the  mass  rarely  attaining  a  size 
greater  than  an  inch  in  diameter.  If  left  alone  they  may  ulcerate  from 
pressure  or  injury,  or,  in  rare  instances,  may  cause  atrophy  and  perfora- 
tion of  the  calvaria  and  dura  mater.  They  should  be  removed  in  early 
childhood.  The  operation  consists  in  dissecting  out  the  sac,  with  its 
contents.  As  a  rule,  small  wounds  of  the  scalp,  situated  where  a  scar 
will  not  be  apparent,  do  not  need  to  be  stitched.  The  edges  should  be 
approximated  and  held  thus  by  a  dressing  of  sublimate  gauze  and  a 
bandage. 

Acquired  cysts,  commonly  called  "wens,"  are  of  two  varieties,  one 
due  to  retention  of  sebum  in  a  sebaceous  follicle,  the  duct  of  which  has 
been  obstructed ;  the  other  caused  by  extravasation  of  blood,  where  the 
clot  has  been  absorbed,  leaving  the  serum  more  or  less  stained  by  the 
decomposition  of  heematin.  They  are  roimd,  smooth  tumors,  are  super- 
ficial, and  found  most  frequently  upon  the  upper  and  posterior  portion 
of  the  scalp.  They  are  mostly  multiple,  are  unilocular,  and  contain  a 
granular,  cheesy  substance.  The  treatment  is  removal  with  the  knife. 
The  hair  should  be  shaved  from  the  tumor,  and  for  a  slight  distance  be- 
yond its  base.  Complete  anaesthesia  can  be  obtained  by  injecting  tti  xv 
of  a  4-per-cent  solution  of  cocaine  in  the  line  of  incision,  and  around 
the  base  of  the  tumor.  With  a  sharp  bistoury  transfix  the  mass  through 
its  base,  and  lay  it  open.  The  integument  over  the  center  of  the  tumor 
will  be  found  exceedingly  thin  (not  thicker  than  ordinary  writing-paper), 
and  may  be  easily  separated  from  the  thickened  sac,  which  should  now 
be  seized  with  a  strong  pair  of  forceps  and  torn  out  of  its  bed.  If  any 
strong  adhesions  are  found  they  should  be  divided  with  the  blunt 
scissors. 

Sebaceous  cysts  occasionally  become  inflamed,  the  capsule  breaks 
down,  the  contents  escape,  and  a  mass  of  granulation-tissue  replaces  the 
original  tumor.     The  new-formed  capillaries  in  this  tissue  frequently  give 


REGIONAL  SURGERY.— THE   HEAD,  383 

way,  causing  repeated  hfemorrhage.  They  should  be  scraped  out  with  a 
sharp  spoon,  and  the  sac  removed  by  dissection. 

Horns,  or  dense  epithelial  outgrowths,  are  occasionally  seen  upon  the 
scalp  and  face.  Some  of  these  excrescences  attain  large  size.  They 
should  be  removed  by  an  elliptical  incision  around  the  point  of  attach- 
ment. The  incision  should  remove  the  entire  thickness  of  the  integu- 
ment. 

Lipomata,  or  fatty  tumors,  are  of  infrequent  occurrence  beneath  the 
scalp,  and,  on  account  of  the  dense  integument,  they  grow  very  slowly, 
and  rarely  attain  large  size.  The  diagnosis  between  sebaceous  and  fatty 
tumors  of  this  region  is  not  always  easy.  The  treatment  is  removal  by 
dissection,  which  is  easily  effected  by  lifting  the  tiimor  from  its  cap- 
sule with  the  finger  or  the  blunt  scissors.  The  capsule  need  not  be  re- 
moved. 

Ncem,  port-wine  marTcs,  and  other  vascular  tumors,  are  quite 
common  upon  the  scalj).  They  have  been  treated  of  in  a  previous 
chapter. 

Papillomata,  or  warts,  occasionally  covering  a  large  territory,  are 
found  in  this  region.  In  one  case  which  came  under  my  care  a  flat  papil- 
loma, two  inches  in  width,  extended  from  the  right  temple  to  the  middle 
line  of  the  scalp.  They  should  be  clipped  closely  with  the  curved  scis- 
sors, their  bases  burned  with  the  actual  cautery  or  nitric  acid,  and  the 
opei-ation  repeated  until  a  cure  is  effected. 

Elephantiasis,  or  general  thickening  of  the  scalp  from  connective- 
tissue  new-formation,  is,  fortunately,  rarely  met  with.  Ligation  of  the 
vessels  feeding  the  diseased  area  will  afford  temporary,  relief,  and  is  a 
justifiable  procedure. 

Hczmatoma  has  been  considered  in  the  chapter  on  Wounds  of  the 
Scalp. 

Abscess  of  the  scalp  requii-es  free  incision,  irrigation,  and  drainage. 
Any  doubts  as  to  the  character  of  the  swelling  may  be  dissipated  by  ex- 
ploration with  the  hypodermic  syringe  and  a  good-sized  needle. 

Pneumatocele,  or  ^^  air -tumor,"  is  occasionally  met  with  beneath  the 
scalp.  It  results  from  disease  or  fracture  of  some  of  the  bones,  permit- 
ting communication  with  the  cavities,  as  the  frontal  sinus,  or  the  Eusta- 
chian tube,  etc.,  and  the  escape  of  air  beneath  the  skin.  Evacuation  of 
the  contents  by  pressure,  with  or  without  puncture,  and  a  compress  to 
prevent  recurrence,  will  produce  inflammatory  adhesions  and  cause  a 
cure. 

Ostitis,  or  periostitis,  is  not  uncommon  in  the  calvaria.  The  causes 
are  the  same  as  for  ostitis  elsewhere.  Great  care  should  be  observed  in 
the  treatment,  on  account  of  the  proximity  of  the  meninges  and  brain. 
Ostitis  with  exfoliation  demands  early  recognition  and  immediate  opera- 
tive interference.  The  rubber  tourniquet  around  the  skull  will  usually 
serve  to  control  bleeding.  A  free  horseshoe  or  crucial  incision  should 
be  made,  and  all  the  diseased  bone  removed  with  the  sharp  spoon. 
When  the  exfoliation  is  confined  to  the  outer  table  of  the  skull  the 
prognosis  is  favorable.     The  wound  should  be  kept  open,  well  drained, 


384  A  TEXT-BOOK  ON  SURGERY. 

and  allowed  to  heal  by  granulation.  If  pus  is  found  beneath  the  inner 
table,  enough  of  the  bone  should  be  cut  away  with  the  rongeur  to  per- 
mit the  free  escape  of  all  the  products  of  inflammation.  The  patient 
should  be  required  to  rest  in  the  position  which  secures  most  perfect 
drainage.     A  loose  antiseptic  dressing  should  be  applied. 

Abscess  of  the  Frontal  Sinuses.— G\sxom.Q.  inflammation  of  these 
sinuses  demands,  as  a  rule,  energetic  and  thorough  operative  measures. 
The  accumulation  of  pus  may  interfere  with  the  integrity  of  the  eye, 
often  breaking  out  through  the  orbit.  Headache,  great  discomfort,  and 
frequent  and  dangerously  high  temperatures  indicate  the  sepsis  which 
is  occurring. 

The  operation  I  prefer  is  the  following:  Shave  the  eyebrow -of  the 
affected  side  and  make  an  incision  through  the  line  of  the  brow  so  that 
when  the  hairs  grow  out  the  scar  will  be  concealed.  The  incision  should 
be  free,  extending  across  the  root  of  the  nose,  if  necessary.  When  the 
bone  is  exposed,  the  sinus  is  entered  by  chiseling  with  a  small  curved- 
edged  instrument  through  the  anterior  lamella  of  the  frontal  bone  at  the 
inner  angle  of  the  supra-orbital  arch  (Fig.  414).  A  light  mallet  should 
be  employed  and  the  chisel  should  be  held  with  the  j)oint  directed  to  the 
nose,  so  that  a  slip  would  not  enter  either  the  eye  or  brain.  Continuing 
into  the  sinus,  an  opening  large  enough  to  admit  the  end  of  the  little  fin- 
ger should  be  made  and  the  walls  of  the  cavity  thoroughly  scraped  with 
the  sharp  sijoon. 

A  strong  dressing  forceps  should  now  be  carried  into  this  opening, 
against  the  upper  turbinated  bones,  and  made,  by  boring,  to  crush 
through  into  the  nasal  cavity.  A  probe  is  next  carried  through  this  hole 
and  brought  out  at  the  nostril  of  the  affected  side,  and  by  this  a  strong 
silk  thread  is  carried  through.  A  good-sized  piece  of  gauze — so  twisted 
that  while  the  end  is  small  as  a  cord  the  middle  portion  is  as  large  as  the 
index-finger — is  tied  to  the  string  and  drawn  through  the  sinus  into  the 
nasal  cavity  and  out  at  the  nostril.  The  entire  twist  of  gauze  is  now 
pulled  through.  This  breaks  away  the  turbinated  bones,  does  not  cause 
annoying  haemorrhage,  and  leaves  perfectly  free  drainage  into  the  nose 
and  mouth.  In  several  cases  which  have  come  under  my  care  this 
method  has  been  attended  with  gratifying  success. 

The  edges  of  the  wound  should  be  united  with  fine  silk  sutures.  In 
cases  where  the  disease  is  unusually  extensive  and  the  discharge  pro- 
fuse, it  will  be  advisable  to  carry  a  small  soft  rubber  drainage-tube  in 
through  the  wound  down  into  the  nose,  leaving  one  end  projecting 
through  the  nostril  and  the  other  at  the  inner  angle  of  the  incision 
above.  For  one  or  two  weeks  after  the  operation  irrigation  through  the 
tube  with  warm  boracic  acid  solution  (gr.  V-3J)  should  be  practiced 
once  a  day.  When  the  tube  is  removed  it  should  be  drawn  out 
through  the  nose.  If  both  sinuses  are  involved,  an  incision  on  one 
side  may  succeed  in  effecting  a  cure  by  breaking  down  the  shell  of 
bone  which  intervenes,  and  passing  beneath  the  root  of  the  nose  into 
the  opposite  sinus,  which  should  also  be  thoroughly  scraped  with  the 
shar]3  spoon. 


1 


REGIOXAL   SURGERY.— THE   HEAD. 


385 


The  effort  to  cure  abscess  of  the  frontal  sinus  by  incision  and  drain- 
age at  the  angle  of  the  orbit  is  not  only  apt  to  fail,  but  it  endangers  the 
integrity  of  the  eye  from  the  presence  of  the  drainage-tube  and  the  accu- 
mulation of  inflammatory  products. 

Osteoma,  or  exostosis,  occurs  quite  frequently  upon  the  bones  of  the 
skull.  "When  not  due  to  sj^jhilis  they  should  be  removed  early,  by  the 
gouge  or  chisel,  as  there  is  always  danger  of  pressure  upon  important 
organs  if  allowed  to  remain.  Syphilitic  hyperostosis  requires  the  specific 
treatment  given  for  this  dyscrasia. 

EncepTialocele,  or  hernia  cerebri,  is  a  protrusion  of  the  brain-substance 
through  an  opening  in  the  calvaria.  This  condition  usually  occurs  in 
children  suffering  fi'om  Jtydrocephalus,  the  protrusion  taking  place 
through  the  abnormally  enlarged  fontanelles.  The  dura  mater  sur- 
rounds and  is  carried  in  front  of  the  mass,  lying  in  contact  with  the  peri- 
cranium. When  the  meninges  alone  protrude,  the  tumor  is  known  as  a 
meningocele. 

Hernia  cerebri  may  occur  after  pei-foration  of  the  skull  from  any 
cause,  as  fracture  or  necrosis.  More  fi'e- 
quently  the  mass  which  protrudes  is  made 
up  of  a  granulation-tissue  containing  no  ele- 
ments from  the  brain-substance,  while  at 
times  these  masses  are  composed  of  both 
brain-  and  granulation-tissue  (Fig.  412).  The 
chai-acter  of  the  tumor  will  be  recognized 
from  its  rapid  development  after  perforation 
of  the  calvaria. 

Treatment. — "Wken  the  mass  is  small,  and 
is  just  beginning  to  project,  compression 
should  be  employed  to  prevent  a  further 
protrusion.  It  is  not  safe  to  attempt  a  re- 
duction of  the  tumor.  The  hair  should  be 
shaved  from  the  scalp  near  the  opening  and 
disinfection  accomplished  by  sublimate  irri- 
gation, and  a  compress  of  sublimate  gauze 
and  absorbent  cotton  applied.     If  the  tumor 

does  not  rapidly  slough  away,  it  should  be  removed  at  the  level  of  the 
scalp  with  the  elastic  ligature  or  the  actual  cautery. 

Sarcoma,  of  the  dura  mater  is  a  grave  condition,  fortunately  of  infre- 
quent occurrence.  In  the  process  of  development  the  tumor  is  apt  to 
cause  absorption  of  the  calvaria,  and  finally  perforation.  This  usu- 
ally occurs  long  after  symptoms  of  pressure  from  within  have  been  de- 
veloped. If  the  patient  survive  the  compression  of  the  brain,  the  tumor 
ultimately  undergoes  necrosis  and  breaks  down  into  a  diity  mass,  in 
which  the  process  of  ulceration  is  accompanied  by  frequent  hjemorrhage. 

Carcinomci  of  the  meninges  may  occur  as  a  result  of  metastasis,  al- 
though rarely  if  ever  occurring  primarily  in  this  situation. 

In  sarcoma  and  carcinoma  of  the  dura  mater  little  more  can  be  done 
than  to  relieve  pain  by  the  emj)loyment  of  narcotics. 
25 


Fig    41    — "\I  t    brain- 

^ub  tan  n  tissue 

remoTed  bv  Dr  E  J  Bcall  from 
a  bov  who  e  skull  had  been  Iraet- 
urei    txaet  size. 


386  A  TEXT-BOOK   ON   SURGERY. 

Hydrocephalus  is  primarily  a  disease  of  the  arachnoid  and  pia 
mater.  It  is  a  disease  of  childhood,  resulting  from  inherited  tubercu- 
losis. The  gross  lesion  is  a  transudation  of  a  serous  fluid  from  the  pia 
and  arachnoid  into  the  cavities  of  the  ventricles,  the  arachnoid,  and  sub- 
arachnoid spaces.  Distention  of  the  ventricles,  compression  of  the  brain- 
substance,  separation  of  the  sutures,  enlargement  and  deformity  of  the 
head,  projection  of  the  eyeballs,  downward  squint,  and  loss  of  cerebral 
function,  are  the  symptoms,  invariably  ending  in  death. 

Treatment. — Tapping  will  at  times  relieve  the  more  urgent  symp- 
toms of  distention  and  compression.  Careful  antisepsis  should  be  prac- 
ticed, and  the  aspiration  made  through  one  of  the  lateral  angles  of  the 
anterior  fontanella.  A  small  needle  should  be  introduced,  and  three 
or  four  ounces  slowly  withdrawn,  the  operation  occupying  from  fifteen 
to  thirty  minutes.  This  treatment  is  palliative,  and  is  only  justifi- 
able in  the  eifort  to  relieve  the  suffering  of  the  patient.  A  cure  is 
impossible. 

Wounds  of  the  scalp  should  be  ti-eated  as  wounds  of  other  parts  of 
the  integument.  Incised  wounds  should  be  rendered  aseptic,  and  may 
be  closed  by  sutures,  or  the  edges  brought  into  apposition  by  a  sublimate- 
gauze  compress  and  bandage,  according  to  the  extent  and  location  of  the 
injury.  Sutures  are  as  well  tolerated  here  as  elsewhere.  When  there  is 
no  especial  desire  to  avoid  a  scar,  sutures  may  be  omitted,  unless  the  wound 
is  so  extensive  and  gaping  that  apposition  can  not  be  effected  by  com- 
pression. Silk  is  preferable  in  stitching  wounds  of  the  scalp.  The  hair 
should  be  trimmed  for  a  fourth  or  half  inch  from  the  edges  of  the  wound. 
When  no  large  vessels  have  been  divided,  the  introduction  of  the  sutures 
will  suffice  to  arrest  the  bleeding.  It  is  a  safe  precaution  to  insert  a  small 
twist  of  catgut  into  one  angle  of  the  wound  to  secure  drainage  in  case  of 
suppuration. 

Lacerated  wounds  of  the  scalp  are  at  times  very  extensive  and  for- 
midable. Several  instances  are  reported  of  complete  avulsion  of  the 
female  scalp  from  the  entanglement  of  the  hair  in  machinery.  In  such 
cases  transplantation  of  integument  becomes  necessary,  in  order  to  pre- 
vent ostitis  from  denudation  of  the  calvaria.  Ordinary  lacerated  wounds 
should  be  rendered  aseptic,  and  treated  by  a  compress  of  sublimate 
gauze.  No  sutures  should  be  employed,  except  when  '  a  scar  is  to 
be  avoided,  and  then  only  after  the  torn  and  bruised  edges  have  been 
trimmed  off  with  the  scissors. 

Contused  wounds  of  the  scalp  are  usually  followed  by  marked  swell- 
ing, due  to  extravasation  of  blood  (hsematoma)  beneath  the  pericranium. 
The  treatment  consists  in  cold  applications,  by  means  of  the  ice-bag  or 
cloths  taken  from  ice-water.  If  suj)puration  occurs,  incision  should  be 
promptly  made.  A  form  of  serous  cyst  sometimes  results  from  hsema- 
toma  of  the  scalp.  It  should  be  treated  by  aspiration,  and,  if  one  or  two 
evacuations  do  not  effect  a  cure,  it  should  be  incised,  and  the  cyst-wall 
dissected  out. 

Gunshot  wounds  in  this  part  require  no  especial  consideration. 

Punctured  wounds  of  the  scalp  are  not  serious,  as  a  rule,  when  no 


1 


EEGIONAL  SURGERY.— THE   HEAD.  387 

poison  is  introduced  througli  tlie  -wound,  and  when  the  bones  are  not 
penetrated. 

Penetrating  Wounds  of  the  Skull. — When  a  foreign  body  has  pene- 
trated the  cranial  cavity  and  passed  out,  and  the  patient  survives  the  im- 
mediate effect  of  the  accident,  the  wounds  of  entrance  and  exit  should  be 
cleansed  of  loose  fragments  of  bone,  or  any  foreign  body.  To  accomplish 
this  it  will  be  not  only  Justifiable,  but  often  imiDerative,  to  enlarge  both 
openings,  by  use  of  the  trephine,  and,  while  employing  strict  antiseptic 
precautions,  to  secure  free  drainage  for  the  discharge  of  blood  or  other 
fluids  from  the  track  of  the  missile.  When  severe  intra-cranial  haemor- 
rhage occurs,  no  attempt  should  be  made  to  arrest  it  by  plugging  the 
wounds  through  the  skull,  for  fatal  compression  of  the  brain  might  thus 
result.  If  the  vessels  involved  can  not  be  reached  from  the  enlarged 
openings,  and  secured  by  heemostatic  forceps  or  the  ligature,  the  head  of 
the  patient  should  be  elevated,  in  order  to  diminish  the  pressure  at  the 
bleeding  point.  This  may  in  part  be  aided  by  ligation  of  the  extremi- 
ties, as  heretofore  described! 

If  there  is  only  a  single  opening,  and  the  body  is  lodged  within  the 
cranium,  a  careful  inspection  should  be  made  about  the  wound  of  en- 
trance, and,  if  the  presence  of  the  missile  can  be  recognized,  it  should  be 
at  once  extracted,  even  if  the  application  of  the  trephine  is  required.  If 
the  bullet  shall  have  entered  the  substance  of  the  brain — which  can  be 
determined  in  part  by  the  careful  employment  of  a  light  Nelaton's  probe, 
provided  with  a  good-sized  porcelain  tij?,  introduced  through  the  wound  in 
the  skull.  sufBciently  enlarged  by  the  trephine— the  probabilities  are  that 
it  has  passed  through  the  brain  in  the  line  of  projection  of  the  missile, 
and  is  lodged  beneath  the  skull,  at  or  near  a  point  dii'ectly  in  the  line  of 
its  projection.  This  condition  was  found  to  exist  in  the  remarkable  case 
operated  on  by  Prof.  W.  F.  Fluhrer,  in  Belle- 
vue  Hospital,  in  1884.     The  patient,  aged  nine-  /^''~7r~~^\ 

teen  years,  received  a  pistol-shot  wound,  enter-  /  \ 

ing  at  the   forehead  and  passing  throiigh  the  /^       ^        I 

brain,  in  the  line  shown  in  Fig.  413.     The  hole  C^'        ^    J 

of  entrance  was  enlarged  by  biting  off  the  edges  y  ' 

of    the    bone   with  a   rongeur.     An    alarming  ^>  z^^^^^^^X 

haemorrhage  from  a  vessel  of  the  pia  mater  was  ^/^^^ /^     n, 

controlled  by  a  small  artery-clamp,  or  forceps.  /   ji_S-^'"~"^  \ 

The  patient's  head  was  placed  so  that  the  sup-       //  /©  f 

posed  track  to  be  explored  was  perpendicular      '    I  ' 

to  the  surface  of  the  table.  A  good- sized  por-  fig.  «3— riuhrer'scaseofpene- 
celain-pointed  Xelaton's  probe  was  carefully  in-  rlrfJJS?'tiffeXhref) 
troduced,   and  allowed  almost  to  find  its  ovm. 

way  in  the  track  left  by  the  bullet.  This  instrument  joassed  to  a  dej^th 
of  six  inches,  where,  a  slight  resistance  being  met  with,  it  was  allowed 
to  remain.  The  direction  of  the  probe  indicated  the  point  on  the  oppo- 
site side  of  the  skull,  at  which  the  missile  had  most  probably  struck. 
Three  fourths  of  an  inch  below  this  line  the  trephine  was  applied.  Upon 
removing  the  disk  of  bone  the  dura  mater  appeared  dark  from  blood 


388 


A   TEXT-BOOK   ON   SURGERY. 


effused  beneatli  it.  An  incision  was  made  througli  this,  and  the  track  of 
tlie  bullet  through  the  pia  mater  was  discovered.  It  had  struck  the  inner 
surface  of  the  calvaria,  had  rebounded  with  a  downward  deflection,  and 
was  found  about  half  an  inch  from  the  hole  made  by  the  trephine.  A 
small  rubber  drainage-tube  was  passed  entirely  through  the  track  made 
by  the  bullet,  and  left  projecting  at  each  opening.  Irrigation  through 
the  tube  was  not  attempted.  The  wounds  were  dressed  with  iodoform- 
ized  gauze,  loosely  laid  on,  and  an  antiseptic  dressing  over  this.  The 
patient  recovered  and  returned  to  his  occupation,  suffering  only  with  a 
slight  impairment  of  memory  and  occasional  muscular  spasm. 

The  imj)ortant  lesson  from  this  case  is,  that  the  careful  exploration  of 
the  cranial  cavity,  and  of  the  brain-substance,  for  the  removal  of  a  foreign 
body,  is  a  rational  and  justifiable  surgical  procedure.  The  careful  em- 
ployment of  a  light,  broad,  dull-pointed  probe  will  enable  the  operator, 
in  a  certain  proportion  of  cases,  to  follow  in  the  track  of  a  foreign  body 
and  indicate  its  place  of  lodgment. 

Not  infrequently  compression  of  the  brain  occurs  from  hfemorrhage 
between  the  skull  and  the  dura  mater,  or  from  a  collection  of  pus,  exos- 
tosis, depression  of  bone,  or  tumor  within  the  cranium.  Within  recent 
years  researches  in  cerebral  anatomy  and  physiology  have  enabled  scien- 
tists to  determine,  with  accuracy  sufficient  to  justify  the  application  of 
their  conclusions  to  surgical  practice,  from  the  distui'bance  of  function 
in  certain  portions  of  the  economy,  the  region  of  the  brain  involved  in 
the  zone  of  compression.     That  portion  of  this  subject  which  is  most 


i;  >lando.    Fissui  e  of  Sylvius. 


41  i.— (Modified  after  Cliampionniere.) 


capable  of  demonstration,  and  therefore  most  practical,  relates  to  the 
interference  with  motion  in  certain  muscles,  or  groups  of  muscles,  which 
have  their  "centers  of  motion"  situated  contiguous  to  the  fissure  of 


REGIONAL   SURGERY.— THE   HEAD.  389 

Eolando,  and  to  certain  disturbances  of  the  mind  and  tlie  senses  chieliy 
located  in  the  cortex  of  the  brain.  According  to  Lucas-Championniere,* 
who  adopts  the  conclusions  of  Charcot  and  Pitres,  our  knowledge  of  this 
subject  may  be  summarized'  as  follows  :  "  In  a  lesion  followed  by  paraly- 
sis of  the  loioer  extremity  the  trephine  should  expose  the  summit  of  the 
ascending  parietal  convolution,  on  both  sides  of  the  upper  end  of  the 
fissure  of  Rolando  (Fig.  414).  Of  the  itpper  extremity,  the  middle  third 
of  the  ascending  frontal  convolution,  also  on  both  sides  of  the  center  of 
the  fissure  ;  upper  and  loioer  extremities,  both  regions  just  given  ;  upper 
extremity  alone,  with  motor  aphasia,  foot  of  third  frontal  and  lower 
third  of  ascending  frontal  convolutions,  in  zone  marked  motor  aphasia 
in  Fig.  414.  Facial  paralysis,  lower  third  of  the  ascending  frontal 
and  foot  of  second  frontal  convolutions.  Aphasia  alone,  foot  of  third 
frontal.^'' 

After  a  careful  analysis  of  all  the  cases  of  cortical  lesions  of  the  brain 
published  in  America,  and  a  thorough  review  of  the  results  of  foreign 
investigators,  Prof.  Starr  arrives  at  the  following  conclusions  :  f 

"1.  Various  powers  of  the  mind  are  to  be  connected  with  activity  in 
various  regions  of  the  brain,  the  surface  of  the  organ  being  the  seat  of 
conscious  mental  action. 

"  2.  The  highest  qualities  of  the  mind — intellect,  judgment,  reason, 
self-control — require  for  their  normal  display  integrity  of  the  entire  brain, 
but  especially  of  the  frontal  lobes.  A  change  of  disi)osition  and  charac- 
ter may  be  considered  as  symptomatic  of  disease  of  the  brain,  and,  in  the 
absence  of  other  symptoms,  of  disease  of  the  frontal  lobes. 

"3.  The  power  of  sensory  perception  is  distributed  over  the  various 
regions  of  the  brain  with  which  the  various  sensory  organs  are  anatomic- 
ally connected.  In  these  regions  objects  are  not  only  first  consciously 
perceived,  but  are  also  subsequently  recognized  ;  and  hence  it  is  in  these 
regions  that  the  memory  pictures  are  stored,  by  whose  aid  the  act  of 
recognition  is  accomplished. 

"  (a)  Disturbance  of  sight,  whether  in  the  form  of  actual  blindness, 
or  of  failure  to  recognize  or  to  remember  familiar  objects,  or  of  hallucina- 
tions of  vision,  may  indicate  disease  in  the  occipital  lobes.  An  examina- 
tion of  the  field  of  vision  will  indicate  which  lobe  is  affected,  since  blind- 
ness in  the  right  half  of  both  eyes  may  be  due  to  destruction  of  the  left 
lobe,  and  blindness  of  the  left  half  of  both  eyes  may  be  due  to  destruction 
of  the  right  lobe. 

"  {b)  Disturbance  of  hearing,  either  actual  deafness  in  one  ear  or  hal- 
lucinations of  sound  on  one  side  (voices,  music.  etc.\  may  indicate  disease 
in  the  first  temporal  convolution  of  the  opposite  side.  Failure  to  recog- 
nize or  to  remember  spoken  language  is  characteristic  of  disease  in  the 
first  temporal  convolution  of  the  left  side  in  right-handed  persons,  and 
of  the  right  side  in  left-handed  persons.     Failure  to  recognize  printed  or 

*  "  La  trepanation  guid^e  par  les  localisations  oerebrales."  V.  A.  Delahaye  et  Cie.,  Paris, 
1878. 

t  "  Cortical  Lesions  of  the  Brain."  M.  Allon  Starr,  from  "American  Journal  of  the  Medi- 
cal Sciences,"  July,  1884. 


390  A  TEXT-BOOK  ON  SURGERY. 

written  language  lias  accompanied  disease  of  the  angular  gyras  at  tlie 
junction  of  tlie  temporal  and  occipital  regions  of  the  left  side  in  three 
foreign  and  in  one  American  case. 

"  (c)  Disturbance  of  smell,  either  as  an  hallucination  or  as  a  loss  of 
power  to  perceive  odors,  may  possibly  indicate  disease  in  the  temporo- 
sphenoidal  region  on  the  base  of  the  brain. 

"  (fZ)  Disturbance  of  taste  can  not,  as  yet,  be  connected  with  disease 
in  any  region.  This  is  due  to  lack  of  care  in  testing  this  sense  in  cases 
of  brain  disease. 

"  (e)  Disturbance  of  general  sensation — including  the  senses  of  touch, 
pressure,  pain,  and  temperature,  together  with  the  sense  of  the  location 
of  a  limb — may  occur  either  in  the  form  of  subjective  perceptions  of  such 
sensations  without  objective  cause,  or  in  the  form  of  impairment  of  these 
sensations.  In  either  case  it  indicates  a  disease  in  the  central  convolu- 
tions, and  possibly  in  the  adjacent  portion  of  the  parietal  lobules. 

"4.  The  power  of  voluntary  motion  of  the  muscles  of  the  opposite  side 
of  the  body  is  located  in  the  two  central  convolutions  which  border  the 
fissixre  of  Rolando.  Motions  of  the  face  and  tongue  originate  in  the  lower 
thii-d  of  this  region  ;  motions  of  the  arm,  in  the  middle  third  ;  motions  of 
the  leg,  in  the  upper  third. 

"  Spasms  in  a  single  group  of  muscles,  or  paralysis  of  a  single  group  of 
muscles,  may  indicate  disease  of  its  motor  area.  Extensive  spasms  or 
paralysis  may  indicate  a  large  area  of  disease  in  this  region  ;  but  if  more 
marked  in  a  single  group  of  muscles  than  in  others  it  may  indicate  a  small 
focus  of  disease  in  the  motor  area  of  that  group  affecting  other  motor 
areas  indirectly  and  coincidently.  Paralysis  following  spasm  in  one 
group  of  muscles  is  a  characteristic  symptom  of  disease  in  the  central 
region. 

"  5.  Disturbance  of  the  power  of  speech  indicates  disease  in  the  convo- 
lutions about  the  fissure  of  Sylvius,  on  the  left  side  in  right-handed  persons, 
and  on  the  right  side  in  left-handed  persons.  If  the  patient  can  under- 
stand a  question  and  can  recall  the  words  needed  for  a  reply,  but  is  un- 
able to  initiate  the  necessary  motions  involved  in  speaking,  the  disease  is 
probably  in  the  third  frontal  convolution,  and  in  the  adjacent  portion  of 
the  anterior  central  convolution.  If  the  patient  can  not  recognize  sijoken 
language,  but  can  repeat  words  after  another,  or  can  use  exclamations 
on  being  irritated,  the  disease  is  probably  in  the  first  temporal  convolu- 
tion. If  the  patient  can  understand  and  can  talk,  but  replaces  a  word 
desii'ed  by  one  that  is  unexpected,  the  disease  is  probably  situated  deep 
within  the  Sylvian  fissure,  or  in  the  white  substance  of  the  brain,  and 
involves  the  association  fibers  which  join  the  convolutions  just  named. 

"  In  making  a  diagnosis  of  cortical  disease  care  must  be  taken  to  dis- 
tinguish between  direct  and  indu-ect  local  symptoms ;  and  also  to  sepa- 
rate clearly  lesions  of  the  cortex  from  those  of  the  vaiious  white  tracts ' 
within  the  substance  of  the  brain." 

As  far  as  the  disturbances  of  motion  are  concerned,  these  points  of 
interest  bear  such  close  relation  to  the  fissure  of  Rolando  that  it  is  neces- 
sary to  determine  approximately  its  location.     Chamiaionniere's  line  is  as 


REGIONAL  SURGERY.— THE  HEAD. 


391 


follows :  From  the  posterior  border  of  the  malar  process  of  the  frontal 
bone,  at  the  upper  outer  angle  of  the  orbit  A  (Fig.  415)  draw  a  line  A  JB, 
directly  backward,  a  distance  of  two  and  four  fifths  inches.  From  B 
draw  a  perpendicular  line,  one  inch  and  one  fifth  long,  to  C,  then  from  C, 
upward  and  backward,  to  D,  which  shall  terminate  in  the  sagittal  suture, 
two  and  one  fifth  inches  directly  behind  the  junction  of  the  coronal  and 
sagittal  sutures,  £J.  The  point  of  junction  of  the  sagittal  and  coronal 
sutures  is  not  always  easily  recognized  in  the  adult.  If,  however,  the 
distance  from  the  root  of  the  nose  (the  naso-frontal  suture)  to  the  poste- 
rior-inferior border  of  the  occipital  protuberance  be  measured,  the  point 
D  (Fig.  415)  will  be  found  to  vary  from  three  quarters  of  an  inch  to  an 


Fig.  415. — (Modified  after  Championniere.) 


inch  posterior  to  the  center  of  this  line.  The  junction  of  the  sagittal  and 
coronal  sutures  is  directly  above  the  external  opening  of  the  auditory 
canal.  The  researches  of  Championniere  may  practically  be  applied  as 
follows :  In  complete  and  persistent  hemiplegia,  where  the  history  of  the 
case  may  exclude  extravasation  in  the  deeper  ganglia,  the  center  or  bit 
of  a  large-sized  trephine  should  be  placed  in  the  middle  of  this  line,  at  2 
(Fig.  415),  on  the  side  opposite  to  the  paralysis.  If  there  is  loss  of  mo- 
tion or  convulsive  movements  of  the  lower  extremity  alone,  the  trej)hine 
should  be  applied  in  the  upper  third  of  the  line,  at  3.  When  the  upper 
extremity  alone  is  involved  (the  lesion  being  probably  in  the  middle  third 
of  the  ascending  frontal  convolution),  the  operation  should  be  performed 
opposite  to  the  middle  and  in  front  of  this  line.  When  simple  aphasia 
is  present,  the  trephine  is  to  be  applied  at  the  lower  end,  and  well  in  front 
of  this  line,  1.  If,  when  the  button  of  bone  is  removed,  the  cause  of  the 
comiDression  is  not  revealed,  the  opening  should  be  enlarged  by  the  ron- 
geur, or  by  reapplying  the  trephine. 

In  elevating  a  portion  of  the  cranial  vault  for  exploration,  or  the  relief 


392  A  TEXT-BOOK  ON   SURGERY. 

of  comjiression  of  the  brain,  the  following  rules  shouW  be  applied  :  The 
entire  scalp  should  be  closely  shaved,  thoroughly  cleansed,  and  rendered 
aseptic.  A  proper  elevation  should  be  given  the  head,  to  suit  the  con- 
venience of  the  operator  and  to  command  the  best  light.  A  rubber  tube 
should  be  carried  around  the  scalp  beneath  the  occiput  and  just  above 
the  ears  and  eyebrows,  thus  in  part  controlling  all  external  bleeding. 
Having  determined  upon  the  point  of  brain  surface  to  be  explored,  make 
this  the  center  of-  a  large  horseshoe-shaped  incision.  If  it  has  been 
determined  to  lift  the  skull  en  masse,  the  horseshoe  flap  should  not 
be  raised  separately,  but  the  bone  having  been  exposed  in  the  line  of 
incision,  the  soft  parts  are  retracted  enough  to  permit  the  division  of 
the  cranial  vault  in  this  line.  This  may  be  done  with  the  Hey  saw, 
rongeur,  or  the  burr-saw  in  use  with  the  dental  engine.  "When  this 
is  done,  an  elevator  may  be  inserted  and  the  entire  piece  lifted  by 
fracturing  the  uncut  isthmus.  The  pericranium  not  having  been  raised, 
the  bone  may  be  replaced  after  the  operation,  without  material  impair- 
ment of  its  vitality. 

The  dura  mater  is  next  opened  by  a  crescentic  or  crucial  incision  and 
reflected.  Any  offending  mass  should  be  removed.  If  nothing  abnor- 
mal appears  upon  exposure  of  the  cerebral  surface,  the  question  of  inva- 
sion of  this  body,  or  of  further  surface  exposure,  must  be  determined  by 
the  gravity  and  prominence  of  the  symptoms  and  the  condition  of  the 
patient.  Heemorrhage  shoiild  be  controlled  by  flne  catgut  ligatures, 
and  by  aseptic  water  at  about  110°.  On  account  of  the  delicate  struct- 
ure of  the  several  vessels,  the  ligatures  should  not  be  drawn  too  tight  or 
any  lateral  traction  made,  for  fear  of  tearing  or  cutting  through. 

The  wound  in  the  dura  should  be  closed  with  catgut  sutures.  A  fine 
catgut  drain  may  at  times  be  indicated.  The  bone  is  next  tui'ued  back 
into  place  and  the  soft  parts  sutiared.  If  only  a  moderate  surface  is  to 
be  exposed,  the  soft  covering  should  be  lifted  separately  and  the  large 
trephine  employed.  The  button  of  bone  removed  has  been  rejolaced  in 
a  number  of  instances  successfully  by  immersing  it  as  soon  as  cut  out 
in  warm  sublimate  (105°  F.)  and  placing  it  again  in  the  hole  from  which 
it  was  taken.  It  would  be  dangerous  to  attempt  restoration  of  the  bone 
when  the  underlying  dura  is  destroyed  or  removed.  The  success  achieved 
in  late  years  in  this  department  of  surgery  by  Horsley,*  Keen.f  Allis, 
and  others  justifies  the  hope  that  still  greater  progress  is  probable  in  the 
near  future.:}; 

*  "American  Journal  of  the  Medical  Sciences,"  April,  1887. 

t  See  same,  October  and  November,  1888. 

I  Tliis  case  of  recent  brain  surgery  (Prof  "W.  W.  Keen,  "  American  .Journal  of  the  Medical 
Sciences,"  October,  1888)  illustrates  so  well  the  value  of  operative  interference  that  an 
abstract  is  appended : 

Tumor  of  Brain-Epilepsy. — A  man,  aored  twenty-six,  at  the  age  of  three  fell  and  struck  his 
head  upon  a  brick.  He  remained  comatose  one  hour.  At  twenty-three  years  of  age  he  had  an 
attack  of  severe  neuralgic  pains.  These  symptoms  increasing,  culminated,  in  February,  1885 
(twenty-four  years  old),  in  epileptic  convulsions,  and,  in  April,  paralysis  of  right  face,  arm,  and 
leg.  Epileptic  attacks  ceased  from  November,  1886,  to  June,  1887.  A  small  scar  a  quarter  of  an 
inch  long  persisted,  located  two  inches  and  a  quarter  to  the  left  of  median  line  and  three  inches 


REGIONAL  SURGERY.— THE  HEAD. 


393 


When  laceration  of  brain  has  been  larodnced  by  fragments  of  bone  or 
other  foreign  substance,  drainage  is  an  essential  feature  of  successful 
treatment ;  indeed  it  is  imperative,  for  drainage  is  as  necessary  in  the 
cranial  cavity  as  elsewhere.  This  point  is  well  illustrated  in  a  brilliant 
case  recently  reported  by  Dr.  Oscar  H.  AUis.*    A  man  received  a  com- 

behind  the  left  external  angular  process.  December  8,  1887,  it  was  tender  to  pressure.  Tem- 
perature over  tbe  scar,  95-5°  F. ;  corresponding  point  on  opposite  side,  94'4°.  December  15, 
1887,  operation  under  ether  and  incision  through  the  scar  down  to  the  bone;  no  indication  of 
injury  to  tbe  bone.  A 
nick  was  made  in  the 
skull  just  at  the  seat  of 
the  scar.  Large  semi- 
elliptical  flap  three  indi- 
es and  a  half  broad; 
convexity  of  incision  pos- 
terior for  drainage  was 
cut  and  turned  forward. 
Trephine  an  incli  and  a 
half  in  diameter  applied 
so  as  to  include  point 
under  the  old  soar.  Dura 
adherent  to  the  button 
in  the  lower  half.  Hard 
mass  recognized,  and  a 
second  button  removed. 
Rongeur  used,  to  fully 
expose  the  remainder 
of  the  tumor.  Dura 
opened.  It  was  adher- 
ent to  the  tumor,  and  a 
portion  of  it  was  re- 
moved with  the  neo- 
plasm, which  was  enu- 
cleated with  the  finger.  Bleeding  controlled  by  fine  catgut  and  hot  water,  1 15°  to  120°  F. 
The  cavity  occupied  by  tuiiior  was  one  half  filled  by  the  resilient  brain  tissue  before  operation 

was  completed.  A  bundle  of  horse- 
hairs for  drains  was  carried  across 
the  wound  and  left  projecting  at 
each  side.  Small  rubber  tube  in- 
serted. Patient  recovered,  im- 
proved in  mind  and  body,  although 
mild  convulsive  movements  oc- 
curred at  rare  intervals. 

Keen  also  proposes  the  follow- 
ing procedure  for  the  relief  of  ab- 
scess of  the  lateral  ventricles  or  in 
hyperdistenlion  by  any  fluid: 

I.  Trephine  half-way  from  the 
external  occipital  protuberance  to 
the  upper  end  of  the  fissure  of 
Rolando,  half  to  three  quarters  of 
an  inch  to  either  side  of  the  mid- 
dle line.  Puncture  toward  the  inner  end  of  the  supraorbital  ridge  of  the  same  side  (Fig. 
415  o.  A).    The  puncture  will  pass  through  the  precuneus,  and  the  normal  ventricle  will  be 

*  "Annals  of  Surgery,"  July,  1889. 


Fig.  415  a. — Diagrarii  of  the  skull  showinf;  the  site  of  the  tumor.  S,  Fis- 
sure of  Sylvius.  li,  Fissure  of  Eokindo.  //-■,  Intraparietal  sulcus.  V, 
Vertical  or  precentral  sulcus.  T,  Temporal  ridge.  I,  II,  III.  the  iirst. 
second,  and  thhd  frontal  convolutions.  The  oval  dotted  line  reiiresents 
tbe  tumor,  the  cross  (  x  )  the  site  of  the  scar.     (Keou.) 


Fig.  415  b. — Appearance  of  the  tumor  with  dura  attached. 
Natural  size.     (Keen.) 


394 


A  TEXT-BOOK   OX  SITEGEET. 


mianted  fractuTe  of  the  frontal  bone,  "vntli  extensiTe  laceiatioiis  of  brain 
tissue.     Tlie  fi-agments  -were  removed  and  ibe  -wotind  cleansed.     The 

lesion  extended  along  the 
frontal  bone  to  its  hori- 
zontal plate,  -wMcli  Tiras 
also  fissttred.  In  order 
to  secure  drainage,  "vdth 
the  finger  of  one  band 
as  a  gnide,  tbe  cribri- 
form plate  of  tbe  eth- 
moid Tvas  bored  tbrongb 
by  a  drill  carried  np 
tbrongb.  tbe  nose  (Tig. 
415  D ).  A  probe  armed 
■with  a  ligatnre  was 
passed  tbrongb  and  a 
rubber  drainage  -  tnbe 
three  eighths  of  an 
inch  in  diameter  pnlled 
through  from  abore 
do^mward,  the  npper 
end  being  left  on  a  level 
Tvith  the  cerebral  sttr- 
fe.ce  of  the  cribriform 
plate.  A  second  tube 
■was  inserted  and  allowed 
to  project  from  the  nose 
and  wotmd  in  the  skull 
(Tig.  41.5  E  and  Fig.  415  r).  An  antiseptic  dressing  was  applied,  and 
the  patient  recovered  without  an  unfavorable  symptom. 


Pig.  415  b.— DriUmg  throngh  the  crihriform  plate.    ( ATlia.) 


Struck  at  some  point  in  tLe  pos- 
terior Lorn  at  from  two  inches 
and  a  qnarter  to  two  inches  and 
three  quarters  from  the  snrface 
of  the  scalp. 

n.  Trephine  at  one  third  of 
the  distance  from  the  glabella  to 
the  upper  end  of  the  fissure  of 
Rolando  and  half  to  tliree  quar- 
ters of  an  inch  to  either  side  of 
the  middle  line.  Puncture  in 
the  direction  of  the  external  oc- 
cipital protuberance  (Tig.  -415  c, 
B).  The  pnnctnre  will  traverse 
the  first  frontal  couTolntion  well 
in  front  of  the  motor  zone,  and 
the  normal  rentride  will  he 
struct  in  the  anterior  horn  at 
about  two  inches  to  two  inches 
and  a  qnarter  from  the  scalp. 


Pig.  ^5  c. — Antero-porferior  section  of  the  head  half  an  inch  from 
the  median  line.  £.  Fissure  of  Eolaudo.  I.  Injpn.  A  and  JB 
(solid !.  lines  of  puncmre.  the  dotted  lines  showins  their  imamP- 
aiy  conannation  to  the  opposite  fixed  poims.     i  After  Keen.) 


lESSIGKAX  SClieEET.— THE  HEAD. 


395 


In  fractal  'Qtrfmgh  "fbs  uridffle  fossa,  -wliere  Mooa.  or  cerebro-sijiiial 

firdd  escajies  tkroTigli  tlie  eaas,  natrnral  drainage  may  be  secured  tliroTigli 
tbe  anditorr  HLeatros.  In  all  sncli  cases  tins  canal  stould  >>e  cleansed 
-wizii  subUmate  soltition,  and  aseptic  cotton  pads  applied  to  alasorb  the 
discliarge  and  prevent  septic  infection. 


i    f 


StreeEET  of  tsu  Face. 

WovMds. — Jneised  -woxmSts  of  the  face  usually  bleed  profusely.     The 

two  essential  features  in  treatment  are  to  arrest  hffimorrhage  and  secnre 
repair  "vrith  the  least  jjossible  deformity.  TThen  the  bleeding  is  only 
slight,  bringing  the  edges  together  with  fine  silk  sutures  will  arrest 
it.    "When  Ugatnres  ai*e  apjjlied,  catgnt  should  inTaiiably  be  emiJoyed. 


896  A  TEXT-BOOK  ON  SURGERY. 

Every  wound  of  ttie  face  should  be  treated  with  the  strictest  antisepsis. 
The  approximation  of  the  edges  should  be  accomplished  v/ith  exactness. 
The  finest  black  iron-dyed  silk  is  the  best  material,  and  the  interrupted 
suture  should  be  preferred.  If  the  character  of  the  hsemorrhage  neces- 
sitates central  deligation,  the  external  carotid  (not  the  common  trunk) 
should  be  tied.  This  necessity  could  scarcely  arise  in  an  incised  wound, 
unless  the  internal  maxillary  or  upper  part  of  the  external  carotid  was 
involved. 

Contusions  of  this  region  require,  as  in  other  parts  of  the  body,  local 
applications,  usually  of  cold  water  or  the  ice-bag.  Ecchymosis  is,  as  a 
rule,  present,  and  is  persistent  in  the  tissues  about  the  eyes. 

Lacerated  wounds  of  the  face  are  serious,  on  account  of  the  danger 
of  disfigurement  after  repair.  If  the  procedure  does  not  involve  much 
loss  of  tissue,  the  edges  may  be  pared  smoothly  and  united  with  silk 
sutures,  under  careful  antisepsis.  If  there  has  been  extensive  contusion, 
a  small  catgut-twist  drain  should  be  left  at  each  end,  to  guard  against 
the  danger  of  infiltration  of  pus  in  the  subcutaneous  tissue.  In  wounds 
which  involve  the  circular  muscles  of  the  eyes  and  mouth,  great  care 
must  be  taken  to  guard  against  contractions  and  deformities. 

Punctured  wounds  require  no  special  consideration.  Deligation  of 
the  external  carotid  may  be  necessitated  to  arrest  bleeding  from  deep 
wounds  of  the  spheno-maxillary  fossa. 

SJiot  wounds  of  the  face  are  not,  as  a  rule,  dangerous  to  life,  even  in 
military  ]practice.  Of  3,312  cases,  in  which  fracture  of  the  bones  of  the 
face  occurred  as  a  result  of  shot  wounds,  as  given  in  the  "Medical  and 
Surgical  History  of  the  Civil  War,"  by  Dr.  George  A.  Otis,  only  340 
died,  while  of  4,914  flesh  wounds  only  58  died.  In  civil  practice  the  rate 
of  mortality  is  still  lower. 

When  the  missile  has  penetrated  the  spheno- maxillary  fossa,  or  di- 
vided any  deep-seated  vessels,  the  necessity  of  tying  the  external  carotid 
may  arise.  A  ball  or  any  foreign  body  lodged  in  the  bones  or  tissues  of 
the  face  should  be  immediately  removed,  when  this  can  be  accomplished 
without  an  operation  which  may  incur  the  danger  of  deformity.  When, 
however,  the  missile  is  deeply  lodged,  and  is  of  small  size,  it  should  not 
be  molested  until  there  is  evidence  that  it  will  not  remain  encapsuled 
and  harmless. 

Bones  or  fragments  of  bone  which  have  been  displaced  in  part,  but 
not  entirely  stripped  of  periosteum  and  vascular  attachments,  must  not 
be  removed,  since,  if  replaced  and  held  in  proper  position,  they  usually 
become  reunited  to  the  sound  bone 

The  Eye. 

Wounds  of  the  eyelids  and  of  the  circular  muscle  of  the  eye  scarcely 
require  special  consideration.  In  incised  or  lacerated  wounds  a  careful 
approximation  of  the  edges  of  such  wounds  with  the  finest  silk  sutures, 
and  the  maintenance  of  the  parts  in  a  condition  of  perfect  quiet,  are 
essential.      The  sublimate  and  carbolic-acid  solutions  can  not  be  em- 


THE   EYE. 


397 


ployed  when  the  siirface  of  the  eye  is  exposed.  A  saturated  soliition 
(about  grs.  xv  to  §j  of  water)  of  boracic  acid  is  to  be  preferred  for 
purposes  of  cleanliness.  Contusions  about  the  eye  should  be  treated 
by  cold  applications,  using  a  very  small  and  light  ice-bag,  or  frequent 
changes  of  bits  of  linen  cloth,  taken  from  a  block  of  ice. 

Neto  Formations. —  Vascular  groicths  (ngevi  or  angeiomata),  usually 
of  the  capillary  variety,  are  not  infrequent  in  the  vicinity  of  the  eye. 
When  of  small  size,  not  exceeding  a  half  or  three  fourths  of  an  inch,  they 
may  be  successfully  destroyed  by  the  hypodermic  injection  of  from  two 
to  five  minims  of  a  50-per-cent  solution  of  carbolic  acid.  Great  care 
should  be  taken  not  to  allow  any  of  the  solution  to  enter  the  eye. 

Removal  by  free  excision  is  not  practicable  when  the  tumor  is  of  large 
size,  and  when  the  paljiebral  margins  are  involved,  or  when  their  shape 
and  situation  are  such  that  deformity  is  apt  to  follow  the  excision.  A 
careful  application  of  the  rules  of  plastic  surgery  to  the  region  of  the 
eye  will  often  obviate  deformity,  even  after  extensive  dissections  with 
loss  of  tissue  in  the  vicinity  of  this  organ.  What  has  been  said  of  the 
excision  of  vascular  growths  applies  equally  to  all  forms  of  neoplasms 
in  this  region  which— themselves  a  deformity,  or  malignant  in  charac- 
ter— require  removal. 

When  this  can  be  done  with  safety,  it  is  of  the  utmost  importance 
that  the  palpebral  margin  be  left  intact  for  at  least  one  eighth  of  an  incli 
in  width,  and  as  much  more  as  is  consistent  with  the  free  excision  of  the 
tumor.     One  incision  should  be  parallel  with  the  border.     The  palpebral 


branch  of  the  ophthalmic  artery,  which  runs  parallel  with  and  about 
this  distance  from  the  free  margin  of  the  lid,  should  not  be  wounded 
when  it  is  possible  to  avoid  it.  When  the  dissection  is  completed,  a 
tongue  of  skin  may  be  slid  from  the  malar  region  across  the  wound,  pro- 
vided the  space  to  be  filled  does  not  measure  more  than  one  inch  in  its 
transverse  diameter.  It  is  at  times  advisable  to  divide  the  tension  by 
sliding  a  shorter  flap  from  the  direction  of  the  nose.  For  larger  spaces 
a  flap  may  be  turned  from  the  cheek,  hand,  or  arm,  as  given  hereafter. 
Fig.  416  represents  the  space  left  after  the  removal  of  a  myxo-sarcoma  of 
the  face,  and  Fig.  416  a  the  method  of  covering  in  the  deficiency.     From 


398 


A  TEXT-BOOK   ON   SURGERY. 


the  outer  angles  parallel  incisions  were  continued  througli  the  skin 
toward  the  ear,  as  far  as  was  necessary  to  secure  integument  enough 

to  slide  across  the  gap.  The 
transverse  facial  artery,  which 
runs  about  one  fourth  of  an 
inch  below  and  parallel  with 
the  zygoma,  should  be  kept 
in  the  flap,  which  is  dissected 
up  until  the  end  nearest  the 
nose  can  be  carried  across  to 
the  edge  of  the  wound  upon 
the  nose  and  stitched  at  this 
point.  The  lower  border  is 
next  fastened,  and  after  this 
the  palpebral  border  is  stitched 
to  the  upper  margin  of  the 
tongue  of  skin  with  the  finest 
siiture  material.  The  sutures 
may  be  removed  in  from  four 
to  six  days.  It  is  necessary 
to  arrest  all  bleeding  from  the 
bottom  of  the  cavity  left  after 
a  dissection ;  that  from  the 
j<i(j  ^15  3  edges  will  be  arrested  by  the 

sutures.  The  tension  on  the 
flap  should  not  be  so  great  that  the  blood-supply  is  seriously  interfered 
with.  After  the  first  sutures 
are  inserted,  it  will  be  well  to 
wait  for  a  few  minutes  in  or- 
der to  see  that  the  circulation 
is  established.  Fig.  416  b  and 
Fig.  416  c  are  taken  from  a 
patient  from  whom  a  large 
nffivus  was  excised,  and  the 
wound  filled  by  free  dissection 
and  sliding  of  the  integument 
of  the  cheek.  Little  or  no 
eversion  or  dragging  down  of 
the  lid  will  follow  in  these 
operations  when  carefully  per- 
formed. 

Sebaceoios  tumors  (reten- 
tion-cysts) are  occasionally  met 
with  on  the  outer  surface  of 
the  lids,  and  in  the  skin  about 
the  orbit.  They  should  be  re- 
moved by  thorough  dissection 
of    the  sac.     When    situated 


THE   EYE.  399 

upon  the  lids  they  rest  between  the  integiiment  and  the  tarsal  carti- 
lage. The  line  of  incision  should  be  parallel  with  the  free  border 
of  the  lid,  to  avoid  dividing  the  horizontal  fibers  of  the  orbicularis 
muscle. 

Hordeolum^  or  "stye,"  is  a  purulent  infiammation  of  the  sebaceous 
gland  and  hair-follicle  at  the  palpebral  margin.  It  is  a  furuncle  of  the 
lid.  Warm  or  emollient  applications  hasten  the  suppurative  process  and 
soften  the  epidermal  covering.  The  treatment  consists  in  early  evacua- 
tion of  the  contents  by  pressure  after  jjricking  the  stye  with  a  delicate 
sharp  lance  or  needle.  Professor  David  Webster  recommends  sulphide 
of  calcium,  gr.  ss.,  twice  each  day  as  a  corrective  and  preventive  of  hor- 
deolum. 

Chalazion. — Obstruction  of  one  or  more  of  the  ducts  of  the  Meibomian 
glands  causes  a  swelling  and  intiammation  of  the  gland,  or  tube  behind 
the  point  of  obstruction.  These  protrusions  appear  on  the  conjunctival 
surface  of  the  tarsal  cartilage,  and  should  be  treated  by  puncture 
through  the  edge  of  the  lid,  with  evacuation  of  their  contents  by  pressure 
on  both  surfaces  of  the  lid,  directed  from  the  base  toward  the  free  bor- 
der, in  the  effort  to  squeeze  out  the  plug  and  thus  restore  the  normal 
condition  of  the  excretory  duct.  Any  incision  on  the  under  surface  of 
the  lids  should  be  made  parallel  with  the  ducts  of  these  glands.  A  rare 
form  of  cystic  tumor  occasionally  develops  in  the  substance  of  the  tarsal 
cartilage.  It  may  be  cured  by  incision  and  destruction  of  the  sac,  or 
by  evacuating  the  contents  and  injecting  one  minim  of  50-per-cent  car- 
bolic acid  into  the  cyst. 

Blepharitis  or  infiammation  of  the  lids  may  affect  all  or  a  limited 
portion  of  these  organs.  It  most  frequently  involves  the  ciliary  margins, 
and  is  known  as  blepharitis  ciliaris.  In  rare  instances  the  cartilages  are 
involved.  Acute  blepharitis  demands  rest  and  local  antiphlogistic  ap- 
plications. Cloths  dijiped  in  warm  water  are  in  general  more  agreeable. 
In  chronic  Uepharitis  ciliaris  the  scaly  covering  of  the  inflamed  borders 
of  the  lids  should  be  removed  by  the  prolonged  use  of  warm  boi'acic-acid 
water  and  a  mop  of  soft  lint,  having  first  trimmed  the  lashes  closely. 
When  this  is  done  the  inflamed  surface  should  be  lightly  touched  with 
a  pencil  of  lunar  caustic.  At  night  the  lids  should  be  lubricated  with  a 
small  quantity  of  cosmoline. 

Blepharospasm,  or  spasm  of  the  orbicularis  palpebrarum  muscle,  re- 
sults usually  from  irritation  of  the  conjunctiva  or  cornea.  It  may,  in 
rare  instances,  occur  without  any  inflammatory  exciting  cause  (idiopathic 
blepharospasm).  The  treatment  is  rest  and  the  removal  of  the  cause  of 
the  spasm.  In  rare  cases  division  of  the  muscle  through  the  outer  can- 
thus  is  demanded  to  relieve  pressure  on  the  conjunctiva,  cornea,  and 
globe. 

Blepharophimosis,  or  narrowing  of  the  palpebral  o]pening,  is  due  to 
contraction  of  the  lids  at  the  outer  canthus  or  angle.  It  may  be  relieved 
by  an  incision  commencing  in  the  outer  angle  and  carried  directly 
out  through  the  entire  thickness  of  the  commissure  for  the  required  dis- 
tance, extending  the  cut  in  the  skin  a  short  distance  farther  than  that 


400  A  TEXT-BOOK   ON   SURGERY. 

in  the  conjunctiva.      The  edges  of  the  sliin  and  mucous  membrane 
are  then  united  by  silk  sutures,  as  shown  in  Fig.  416  d. 

Lagophthalmos.  —  Inability     to 
/  close  the  eyelids  may  be  due  to  pro- 

,^  /  trusion  of  the  globe  from  tumors  of 

the  orbital  cavity,  or  of  the  globe  ; 
\  it  occurs  in  the  disease  of  which  en- 
largement of  the  thyroid  body  and 
"  exophthalmos  "  are  symptoms  ;  in 
staphyloma  and  in  paralysis  of  the 
facial  nerve.  It  is  a  serious  condi- 
tion, on  account  of  the  liability  of 
ulceration  of  the  cornea  from  pro- 
longed exposure  of  the  anterior  sur- 
face of  the  globe.  The  indications 
in  treatment  are  first  palliative  in 
keeping  the  lids  closed  by  bandag- 

FiG.  416  D. — Incision  and  sutures  in  operation  for       .  .   .         ,,  ,  . 

blepharophimosis.     (De  Wecker.)  lUg,  Or  UUltlUg  the  edges  by  SUtUreS. 

When  the  condition  is  permanent, 
the  operation  of  farsorapJiy  is  to  be  performed  as  follows :  Introduce  a 
horn  spatula  between  the  globe  and  the  lids  at  the  outer  canthus  ;  make 
the  tissue  tense,  and  with  a  sharp  knife  remove  the  free  borders  of  the 
upper  and  lower  lid  for  a  distance  sufiicient  to  close  the  eye  to  the 
desired  extent.  The  incision  should  remove  the  roots  of  the  cilige.  The 
opposing  edges  are  now  united  with  silk  sutures. 

Blepharoptosis. — Ptosis,  or  inability  to  lift  the  upper  lid,  may  be  due 
to  partial  or  complete  paralysis  of  the  third  nerve,  or  the  filament  which 
supplies  the  levator  palpebrse ;  to  adhesions  from  inflammatory  affec- 
tions of  the  lid  ;  to  the  presence  of  neoplasms  or  to  acquired  or  congeni- 
tal weakness  of  the  levator  muscle.  In  ptosis  due  to  paralysis  when 
electricity  fails  to  restore  the  function  of  the  muscle  or  nerve,  it  may  be 
corrected  by  excising  an  elliptic-shaped  piece  of  the  skin  of  the  upi^er 
lid,  including  the  areolar  tissue  and  the  fibers  of  the  orbicular  muscle. 
The  lower  incision  should  run  parallel  with  the  margin  of  the  lid  and 
about  one  quarter  inch  above  it.  The  edges  of  the  two  incisions  should 
be  united  with  silk  sutures. 

SyniblepTiaron  is  a  term  applied  to  adhesions  of  the  lids  to  the  ocu- 
lar conjunctiva.  Limited  adhesions  may  be  broken  up  repeatedly  until 
a  cure  is  effected  by  the  extension  of  an  epithelial  covering  over  the 
granulating  surfaces.  When  the  adhesions  are  extensive,  Teale's  opera- 
tion may  be  jjerformed. 

Supposing  the  condition  shown  in  Fig.  416  e  to  exist,  the  sym- 
blepharon  is  cut  through  at  A,  in  the  line  of  the  corneo-sclerotic  junc- 
tion, and  the  lid  is  dissected  up  to  the  normal  fold  of  palpebral  and 
ocular  conjunctiva  (D,  Fig.  416  f).  Two  flaps  {B  and  (7,  Fig.  416  f) 
are  now  dissected  up  from  the  conjunctiva,  and  turned  down  and 
stitched  in  position  to  cover  the  raw  surface  left  by  the  dissection  of 
the  adhered  lid.     The  spaces  left  by  lifting  the  flaps  are  closed  at  once 


THE  EYE. 


401 


by  fine  silk  sutures  (Fig.  416  g).     The  island  of  tissue  left  on  the  cornea 
is  allowed  to  disappear  by  atrophy. 


Fig.  416  e. 
SymblepharoD.  A,  Incision 
through  the  attached  con- 
jxmetiva  at  the  comeo-scle- 
rotic  junction.  Teule's  op- 
eration.    (Swanzy.) 


Fig.  416  f. 
The  same,  i",  Adherent  con- 
junctiva dissected  down. 
£,  C,  Incision  for  flaps  to 
cover  this  wound.  (Swan- 
zy.) 


Fig.  416  g. 
The  same.  A.  Tip  of  sjm- 
blcpharon  left  to  disappear 
by  absorption.  C,  JS,  Flaps 
turned  and  sewed  into  new 
position.  D,  £,  Wounds 
closed  by  sutures.  (^Swanzy.) 


Ectropion,  or  eversionof  the  lid,  may  he  partial  or  complete,  and  is 
due  first  to  weakness  of  the  orbicularis  palpebrae  muscle,  especially  to 
the  palpebral  fibers  ;  second  to  cicatricial  contractions  due  to  injury  or 
disease  of  the  soft  parts  above  the  eye,  or  of  the  bones  surrounding  the 
orbital  cavity.     The  lower  lid  is  usually  involved. 

The  treatment  is  operative.  In  mOd  cases,  those  in  which  no  cica- 
tricial adhesions  have  occurred,  the  following  operation,  as  given  by 
Swanzy,  is  advised  : 

Metliocl  of  A.  Robertson. — Thread  a  long  quarter-curved  needle  with 
each  end  of  a  small  Chinese  twisted-silk  ligature,  about  fifteen  inches 
long  ;  with  one  of  these  perforate  the  entire  thickness  of  the  lid  one 
line  from  the  ciliary  margin  and  one  quarter  of  an  inch  to  the  outer  side 
of  the  center  (6,  a,  Fig.  416  h). 
The  needle  is  now  passed  over  the 
conjunctival  surface  of  the  lid, 
till  it  meets  the  fold  of  conjunc- 
tiva reflected  from  the  lid  on  to 
the  globe  through  which  the  needle 
is  thrust — the  point  being  direct- 
ed slightly  forward — and  pushed 
slightly  downward  under  the  skin 
of  the  cheek  until  a  point  is 
reached  from  one  to  one  and  a 
quarter  inch  below  the  edge  of 
the  lid,  where  it  is  brought  out. 
The  other  needle  is  introduced  in 
a  corresponding  manner  at  the 
same  distance  from  the  middle 
line  on  the  inner  side  (a',  &',  d'. 
Fig.  416  II). 

A    piece    of    thin    sheet -lead, 
about  one  inch  long  and  one  quarter  inch  broad,  rounded  at  its  ex- 
tremities and  smooth  on  all  surfaces  and  edges,  bent  to  fit  the  curva- 
ture of  the  eyeball,  is  now  slipped  under  the  loops  of  the  ligature  that 

26 


—  b 


■"^" 


Fig.  416  h. — ^Eobertson's  operation  for  ectropion 
of  the  lower  lid.     (-i.  Eobertson.) 


402 


A  TEXT-BOOK   ON  SURGERY, 


pass  over  the  conjunctiva]  surface  of  the  lid ;  at  the  same  time  a  short 
piece  of  small  rubber  drainage-tube  is  passed  beneath  the  loop  on  the 
cutaneous  surface  just  below  the  ciliary  margin.     Now,  as  the  ends  are 


Fio.  416 1. — Jaeger's  plate  lid-holder. 


drawn  gradually  tight,  the  edge  of  the  lid  is  made  to  revolve  inward 
over  the  upper  edge  of  the  piece  of  lead,  while  the  tarsal  cartilage  is 
molded  to  the  curve  of  the  lead,  and  the  lid  assumes  its  normal  position. 
The  threads  are  tied  below  over  the  rubber  tube,  d^  d.  The  sutures 
and  lead  are  removed  from  the  fourth  to  the  sixth  day. 

In  mild  ectropion,  due  to  limited  cicatricial  adhesions,  Wharton 
Jones's  V  Y  operation  may  be  adopted. 

As  shown  in  Fig.  416  j,  a  V-shaped  incision  is  made  so  as  to  include 
the  scar,  the  flap  dissected  up,  and  the  underlying  cicatricial  adhesions 
cut  out.  The  lid'  is  lifted  into  its  normal  position,  stitched  to  its  up- 
per fellow,  if  necessary,  to  hold  it  in 
place,  and  the  edges  of  the  wound 
sutured  from  below  upward,  leaving 
a  Y-shaped  scar  (Fig.  416  k). 


Fig.  416  j. — Wharton  Jones's  operation 
for  ectropion  of  the  lower  lid.  (De 
Wecker.) 


Fig.  416  k. — The  same,  after  the  flap  is 
dissected  up  and  the  sutures  tied. 
(De  Wecker.) 


Fig.  416  l. — Complete  ectropion  of  lower  lid,  due  to 
cicatricial  contractions  after  ostitis  of  the  orbital 
margin. 


THE  EYE. 


403 


In  more  extensive  adhesions  (Fig.  416  l),  in  which  neither  of  the 
foregoing  methods  will  meet  the  indications,  a  jDlastic  operation  is  in- 
evitable.    Make  one  incision,  parallel  with  the  free  border  of  the  lid, 


^<^ 


Fig.  416  M. 
Showing  the  cicatricial  tissue  dissected  out,  and  the  flap  to  be  turned  from  the  cheek  outlined. 

which,  shall  extend  beyond  the  cicatricial  tissue  to  be  removed.  Dis- 
sect out  freely  all  adhesions  and  cicatricial  material,  until,  when  left  to 
itself,  the  remaining  edge  of  th*e  lower  lid  rises  into  its  natural  posi- 


FiG.  416 N. 

The  flap  stitched  into  position,  and  the  wound  formed  by  its  removal  closed. 

The  lids  temporarily  sutured. 

tion.  In  order  to  fiU  the  deep  oval  cavity  (Fig.  416  m)  left  by  such 
dissection,  a  flap  may  be  turned  from  the  cheek,  forehead,  or  arm.  The 
plan  of  the  flap  from  the  cheek  is  shown  in  Fig.  416  n.  It  should  be 
cut  by  measurement,   so  as  to  fit  without  tension.     As  soon  as  it  is 


404 


A  TEXT-BOOK  ON  SURGERY. 


turned  across  to  its  new  position,  the  eyelids  should  be  stitched  to- 
gether, and  the  iiap  accurately  and  carefully  stitched  to  the  margins  of 
the  elliptical  wound.  Before  the  lower  row  of  sutures  are  inserted,  the 
edges  of  the  perpendicular  wound  from  which  the  flap  was  I'emoved 
should  be  a]3proximated  by  sutures  of  fine  silk,  which  material  should 
be  used  throughout.  The  stitches  are  to  be  removed  on  the  fifth  day. 
If  any  puffing  remains  at  the  seat  of  the  pedicle  of  the  flap,  it  may 
be  relieved,  after  a  few  months,  by  dissecting  out  a  small,  elliptical  piece 
and  bringing  the  edges  together.  As  it  is  often  desirable  to  avoid  a 
scar  upon  the  face,  an  effort  should  be  made  to  fill  the  cavity  left  by 
dissecting  out  cicatricial  tissue  by  turning  a  flap  from  the  ulnar  border 
of  the  palm  of  the  hand,  which  is  free  from  hairs. 


.  Fig.  416  o. — Knapp'a  entropion  forceps,  or  clamp. 


Entropion,  inversion  of  the  lid,  usually  results  from  chronic  inflam- 
mation of  the  conjunctiva  and  tarsal  cartilage.  It  is  more  frequent  in 
the  upper  lid.     In  mild  cases  relief  may  be  obtained  by  excising  an 


Fig.  416  p. —Lid 


alpels 


elliptical  strip  of  the  integument  of  the  lid  and  stitching  the  edge  of 
the  wound  together.     When,  however,  the  tarsal  cartilage  is  involved, 
Snellen's  method  will  prove  more  satisfactory. 
With  Knapp's  clamp  applied,  make  an  in- 
cision through  the  skin  one  eighth  of  an  inch 
from  and  parallel  with  the  whole  length  of  the 
margin  of  the  lid.     Lift  the  sMn-flap,  expose 
the  fibers  of  the  orbicularis  muscle,  and  excise 
a  strii?  of  the  muscle  about  one  twelfth  of  an 
inch  wide  for  the  full  length  of  the  incision. 
The  tarsal  cartilage  is  now  seen,  and  from  it 
as  far  as  it  is  exposed  a  wedge-shaped  piece 
is  excised  with  a  sharp  knife   (Fig.   416  q). 
The  apex  of  the  wedge  points  toward  the  con- 
^'■"siitwinglScto^ofdiL^^^^^^^^        junctiva,  but  the  section  should  not  extend 
The  muscular  strip  and  a  trian-     entirely  through  the  Cartilage.     Three  sutures 

gular  strip  ot  the  tarsal  cartilage  ^  n  o 

are  removed.   (De  Wecker.)        are  uow  inserted,  each  entering  from  without 


THE   LACHRYMAL  GLAND  AND  DUCTS.  405 

inward,  traversing  the  skin  and  muscle  (Fig.  416  k)  of  tlie  strip  left  at 
the  palpebral  margin ;  then  in  the  same  direction  it  is  carried  across 
the  wound  into  the  upper  bevel  of  the  incision  in  the  cartilage,  from 
which  it  emerges  (without  transfixing  the 
integument  of  the  flap),  to  be  again 
brought  out  through  the  tissues  it  first 
entered,  about  one  eighth  of  an  inch  dis- 
tant from  the  point  of  entrance.  Each 
end  of  the  suture  is  fastened  with  a  shot, 
to  prevent  it  cutting  through. 

Eczema  of  the  eyeKds  is  not  of  very 
frequent  occurrence.  Swanzy  recom- 
mends  the  daily  removal  of   the  crusts  by       Yw   416e— Front  view  ^Uhe  same,  ^ith 

bathing  the  parts  in  a  warm  solution  of  (De  WeckTnf^'*  '^'"^^  *°  ^^  ''"^ 

bicarbonate  of  potash,  drying,  and  then 

painting  with  solution  of  nitrate  of  silver  (gr.  xx  to  water  §  j ) ;  after 
this  an  ointment  of  boracic  acid  (gr.  xxx  to  3  j)  is  applied. 

Epicanthus. — This  term  is  applied  to  a  congenital  defect  which  con- 
sists of  a  fold  of  skin  stretched  across  the  inner  canthus  and  the  carun- 
cula.  It  may  be  relieved  by  excising  an  elliptical  piece  of  integument 
in  the  long  axis  of  the  nose  just  between  the  eyes.  The  width  of  the 
excised  portion  must  be  sufficient  to  remove  the  deformity  when  the 
edges  of  the  wound  are  drawn  together  by  sutures. 

Restoration  of  the  Eyelids. — In  destruction  of  the  lids  by  accident  or 
disease  it  becomes  necessary  to  restore  the  covering  to  the  globe.  Flaps 
may  be  turned  from  the  neighboring  healthy  integument  or  borrowed  by 
a  plastic  operation  from  the  arm.  In  many  cases  much  damage  may  be 
prevented  by  applying  good-sized  and  numerous  grafts  to  the  exposed 
surfaces  while  granulation  is  going  on. 

The  Lachrymal  Gland  and  Ducts. 

Disease  of  the  lachrymal  gland  is  rare.  In  inflammation  of  this 
organ  {dad'yoadenitis)  tenderness  and  swelling  may  be  observed  in  the 
upper  outer  portion  of  the  orbital  cavity.  In  well  marked  enlargement 
from  any  cause,  the  eyelid  is  pushed  forward  and  the  globe  displaced 
downward  and  inward.  An  abscess  here  should  be  opened  by  puncture 
through  the  base  of  the  lid  at  the  most  convenient  point.  When  a  neo- 
plasm develops  in  the  gland,  extirpation  should  be  done  by  incision  in 
the  fold  of  the  lapper  lid,  just  beneath  the  brow. 

Epiphora,  or  continual  overflow  of  tears,  is  caused  by  obstruction  in 
the  system  of  canals  which  normally  should  conduct  the  secretion  of  the 
lachrymal  gland  from  the  margins  of  the  lids  into  the  nasal  cavity,  or 
by  displacement  of  the  punctum  lachrymale,  so  that  the  tears  can  not 
enter  the  orifice.  On  account  of  its  position,  the  lower  canaliculus  is  of 
much  more  importance  to  the  drainage  of  the  eye  than  the  upper. 

Epiphora  due  to  disturbance  of  the  canaliculus  may  be  present  as  a 
symptom  of  any  displacement  of  the  lov^er  lid,  from  swelling,  paraly- 


406  A   TEXT-BOOK   ON   SURGERY. 

sis,  or  cicatricial  contraction,  the  direction  of  the  pnncture  being  so 
changed  that  neither  gravity  nor  the  normal  suction-force  will  carry  the 
secretion  into  the  opening.  Occlusion,  partial  or  complete,  may  occur 
either  from  lodgment  of  foreign  substances,  products  of  inflammation, 
pus,  epithelia,  etc.,  and  occasionally  to  calcareous  formations  (fla- 
cryolitlis). 

The  most  common  form  of  obstruction  is,  however,  met  with  in  the 
nasal  portion  of  the  excretory  apparatus.  Catarrhal  inflammation  of  the 
mucous  membrane  lining  the  canal  or  cyst  may  occlude  the  duct  either 
by  approximation  of  the  walls  or  by  excessive  secretion  of  tenacious 
mucus.  Such  condition  is  met  with  in  patients  of  all  ages,  occurring 
chiefly  in  the  poorly  nourished  and  scrofulous  or  tuberculous  subjects, 
who  suffer  from  chronic  nasal  catarrh  and  ophthalmia,  or  ostitis  of  the 
neighboring  bones.  As  a  result  of  obstruction  in  the  nasal  duct,  dacryo- 
cystitis, or  inflammation  of  the  lachrymal  sac,  may  ensue  with  disten- 
tion, the  swelling  showing  beneath  the  skin  at  the  inner  angle  of  the 
eye  {muco-cele). 

The  treatment  of  displaced  punctum  laclirymale  should  be  directed 
to  the  restoration  of  the  lid  to  its  normal  position.  In  partial  obstruction, 
due  to  catarrhal  conditions,  relief  may  be  obtained  by  slitting  the  canal 
with  the  canaliculus  knife  or  scissors,  and  frequently  repeated  irrigations 


Fig.  417. — Agnew's  canalieula  knife. 

with  the  lachrymal  syringe.  When  obstruction  occurs,  dilatation  by 
means  of  probes  is  indicated.  Should  the  stricture  be  close  and  resist- 
ing, the  knife  should  be  carefully  introduced  and  a  division  effected,  the 
dilatation  being  continued  by  inserting  the  probes  at  intervals  of  two  to 
six  days.  The  prognosis  in  many  cases,  no  matter  how  faithfully  and 
skillfully  treated,  is  not  favorable. 

In  slitting  up  the  canaliculus  the  delicate  probe-pointed  knife  or  scis- 
sors should  be  introduced  at  the  inferior  punctum,  and  carried  toward 
the  canthus  for  a  distance  of  about  one  sixth  of  an  inch,  the  slit  extend- 
ing for  this  distance.  The  wound  should  be  kept  open  by  forcibly  sepa- 
rating the  edges  once  or  twice  a  day,  until  the  cut  surfaces  are  covered 
with  epithelium  and  the  trough  becomes  permanent.     Some  operators  in 

clironic  dacryo  -  cysti- 
tis prefer  to  slit  the 
upper  canaliculus  and 
pass  the  probes  by 
this  route.     The  bulb- 

Fio.  417  A.— Theobold's  lachrymal  probes.  poluted  dilating-probeS 

should  now  be  careful- 
ly introduced,  beginning  with  the  smaller  sizes  (Fig.  417).  As  soon 
as  the  bulb  enters  the  sac,  it  should  be  gently  and  slowly  directed 
along  the  nasal  duct  until  it  is  arrested  by  the  floor  of  the  nose.  The 
larger  sizes  may  be  introduced  as  in  the  treatment  of  stricture  of  the 


THE    COXJryCTIVA   AND    CORXEA. 


407 


Fig.  417  b. — Anel's  STTinjre. 


urethra.  After  full  dilatation  is  secured  the  channel  should  be  washed 
out  daily,  for  about  ten  days,  vrith  a  1-per-cent  boracic-acid  solution. 
For  this  purpose  Anel's  syringe  (Fig.  417  b)  will  be  found  useful.  The 
probe-pointed  nozzle  is  intro- 
duced into  the  sac  and  the 
water  forced  through  until  it 
flows  freely  into  the  nose.  If 
the  obstruction  recurs,  the 
probes  should  be  reintroduced 
at  regular  intervals,  gradually 
increasing  unril  a  permanent 
opening  is  efEected. 

Trichiasis,  or  turning  in  of  the  eyelashes,  occurs  with  entropion,  but 
may  exist  independently.  Occurring  with  inversion  of  the  lid,  it  does 
not  require  any  other  interference  than  that  given  for  the  cure  of  entro- 
pion.    When  the  ciliEe  turn  in  without  inversion  of  the  lid,  the  proper 

method  of  treatment  is  total 
excision  of  the  hair- follicles. 
This  should  be  accomplished 
by  two  parallel  incisions  made 
along  the  margin  of  the  lid, 
one  on  either  side  of  the  row  of 
hairs,  and  extending  deep  enough  to  insure  the  complete  removal  of 
the  roots  of  the  cLLige.  When  only  a  few  hairs  are  at  fault,  the  follicles 
may  be  destroyed  by  the  galvanic  needle.  When  depilation  is  de- 
manded, the  instrument  shown  in  Fig.  417  c  will  be  found  of  great 
service.  In  disticTiiasis  there  is  an  extra  row  of  cilise ;  these  require 
removal  by  the  method  just  given. 


fjreeps. 


The  Coxjo'ctita  axd  Corxea. 

Conjunctivitis  may  be  acute  or  chronic,  and  circumscribed  or  diffuse. 
Simple  conjunctivitis  may  result  from  prolonged  strain  or  over-use  of 
the  eyes,  from  the  lodgment  of  foreign  particles,  or  exposure  to  strong 
winds.  The  hypercemia  may  be  confined  to  a  limited  portion  of  the 
mucous  membrane,  or  spread  over  the  entire  palpebral  and  ocular  con- 
junctiva. 

The  treatment  consists  in  the  instillation  of  two  or  three  drops  of 
cocaine,  two  to  four  per  cent  solution,  at  intervals  of  from  one  to  several 
hours,  the  removal  of  any  foreign  matter,  rest  by  closure  of  the  lids,  or 
the  dark  room  and  the  application  of  soft  cloths  taken  from  cold  boracic- 
acid  solution  (grs.  x  to  3  jj  or  from  a  block  of  ice. 

Follicular  conjunctivitis  may  follow  an  acute  simple  inflammation, 
and  is  characterized  by  the  development  of  small  red  points  or  elevations 
scattered  over  the  deeper  portions  of  the  palpebral  surfaces  of  the  mucous 
membrane  and  the  contiguous  reflection  of  the  ocular  conjunctiva.  The 
elevations  are  swollen  and  distended  lymphatic  channels  and  follicles. 
The  disease  is  characterized  by  considerable  pain,  inability  to  use  the 


408  A  TEXT-BOOK   OX  SURGEEY. 

eyes,  and  a  sensation  as  if  a  gritty  or  sandy  substance  were  present.  In 
treatment  the  condition  of  the  general  system  should  be  improved  by 
tonics  and  nutritious  diet ;  rest  to  the  diseased  organs,  and  the  daily 
application,  by  means  of  a  camel' s-hair  brush,  into  the  conjunctival  sac 
of  a  small  mass,  about  one  eighth-inch  diameter,  sulphate  of  copper  gr. 
ss.  to  ij  in  3  3  vaseline  (Swanzy). 

Granular  Conjunctivitis  {TracJioma). — It  is  not  yet  positively  known 
whether  there  is  any  real  pathological  difference  between  follicular  and 
granular  disease  of  the  conjunctiva.  '  Some  observers  hold  that  the  latter 
is  but  an  exaggerated  and  chronic  form  of  follicular  conjuncti^'itis.  The 
weight  of  opinion,  however,  favors  the  non-identity  of  the  two  diseases. 
Trachoma  is  chiefly  met  with  among  the  lower  classes — the  poorly  fed 
and  overcrowded,  who  live  in  damp  and  unwhole- 
some surroundings.  It  is  held  to  be  contagious 
at  all  times,  and,  in  the  more  violent  forms,  when 
a  muco-purulent  discharge  is  plentiful,  the  conta- 
gious nature  of  the  affection  is  evident  (Fig.  418). 
In  the  earlier  stages  there  appear  upon  the 
lower  lid  round,  granular  elevations,  vesicular  at 
Granular  lower  ud.  (Ebie.)  times,  Scattered  here  and  there,  or  the  whole  mu- 
cous membrane  may  be  thickly  studded.  As  a 
result  of  the  chronic  inflammatory  process  the  lid  is  at  first  thickened. 
As  the  process  is  continued,  connective  tissue  is  developed  with  the 
usual  cicatrization  and  contraction,  causing,  in  obstinate  cases,  deformi- 
ties of  the  lids  and  great  and  persistent  discomfort. 

The  treatment  includes  the  measures  just  given  for  follicular  con- 
junctivitis. In  addition,  either  the  sulphate  of  copper  stick  or  nitrate 
of  silver  in  strong  solution — grs.  x-xx  to  §j — or  the  mitigated  lunar 
caustic.  Nettleship  advises  the  following  strength  :  "Nitrate  of  silver, 
one  part ;  nitrate  of  potash,  two  parts,  fused  together  and  run  into  molds 
to  form  short  pointed  sticks  ;  used  for  granular  lids  and  purulent  oph- 
thalmia." The  application  should  be  made  every  day,  or  less  frequent- 
ly, as  may  be  demanded.  When  these  measiires  fail,  canthoplasty  may 
be  done  and  the  diseased  tissue  dissected  from  the  lids. 

Oonorrhmal  OpMhalmia. — Conjunctivitis  caused  by  the  introduction 
of  the  virus  of  gonorrhoea  into  the  eye  should  be  treated  with  great  care 
and  persistency  from  the  first  symptom  of  this  painful  affection.  Usually 
a  single  organ  is  attacked.  It  is  important  that,  while  the  effort  to  cure 
one  eye  is  being  made,  the  other  should  be  protected  from  the  contagion. 
To  effect  this,  a  watch-glass,  to  the  edge  of  which  adhesive  plaster  is  at- 
tached, is  placed  over  the  sound  eye  and  closely  fastened  to  the  skin 
about  the  orbit  by  the  plaster,  so  that  it  is  hermetically  sealed.  This 
should  not  be  removed  until  the  other  eye  is  well. 

In  the  local  treatment  of  the  affected  eye  it  is  required  to  remove  the 
purulent  discharge  by  frequent  irrigation  ■ndth  warm  boracic-acid  water 
or  by  the  pellets  of  lint  or  absorbent  cotton,  and  to  brush  over  the  everted 
lids  once  or  twice  a  day,  as  the  attack  is  light  or  severe,  a  solution  of 
nitrate  of  silver  (grs.  xx  to  5j).     The  excess  should  be  immediately 


THE    COXJUXCTIVA   AND    CORNEA.  409 

washed  off  with,  tepid  water.  Cold  applications  are  of  great  importance, 
and  a  very  efficient  method  is  to  apply  frequent  changes  (svery  one  or 
two  minutes )  of  pieces  of  lint  about  two  inches  square,  which  are  taken 
directly  from  a  block  of  ice  and  laid  over  the  inflamed  organ.  In  this 
form  of  conjunctival  inflammation,  as  in  others  where  the  injection  is 
marked  and  the  thickening  great,  and  where  painful  NepTiarospasm 
occurs,  or  where  a  free  discharge  of  purulent  matter  can  not  be  effected 
by  ordinary  means,  canthoplasty  is  required.  This  operation  consists 
in  slitting  the  outer  canthus  in  the  direction  of  the  ear,  and  in  this  way 
dividing  the  fibers  of  the  orbicular  muscle. 

In  gonorrhoeal  conjunctivitis  the  impairment  of  function  in  the  mus- 
cle is  not  intended  to  be  of  long  duration,  and  the  wound  is  left  open. 
In  some  cases  of  spasm  of  this  muscle,  and  where  a  chronic  inflammation 
exists,  the  mucous  membrane  is  stitched  to  the  skin  along  the  edges  of 
the  wound,  thus  preventing  a  reunion.  Eeunion  may  be  effected  later 
by  paring  the  edges  and  bringing  the  parts  together  after  the  lesion  for 
which  the  canthoplasty  was  performed  is  healed.  Cocaine  should  be 
used  to  relieve  pain,  and  all  adhesion  between  the  ocular  and  palpebral 
mucous  surfaces  should  be  broken  up  as  soon  as  discovered. 

Conjunctivitis  in  the  new-born  UrpJiUtalnua  neonatorum)  is  a  form  of 
purulent  ophthalmia  which  usually  results  from  the  inoculation  of  the 
conjunctiva  with  septic  matter  present  in  the  genital  passages  of  the 
mother.  It  may  come  from  carelessness  on  the  part  of  the  nurse,  herself 
affected  with  a  leucorrhoea.  etc.,  or  from  the  lodgment  of  any  virus  in  the 
eye  of  the  child.     The  treatment  is  propTiylactlc  as  well  as  curative. 

The  eyes  of  a  child  bom  of  a  mother  known  to  be  suffering  from  a 
vaginal  discharge  of  a  purulent  character  should,  as  soon  as  possible 
after    birth,   be  washed   or  mopped    out  with  clean  warm  water,    or 


Fig.  41S  a. — Drop-glass  for  the  eye. 

boracic-acid  solution,  to  be  followed  with  one  or  two  drops  of  a  2-per- 
cent nitrate-of-silver  solution  (grs.  ijss.  —  3J)  once  or  twice  a  day,  for 
three  or  four  days. 

When  the  disease  is  declared,  the  pus  should  be  gently  removed 
from  the  eye  by  pellets  of  soft  lint  or  absorbent  cotton,  dipped  in  warm 
boracic-acid  solution,  the  lids  everted,  and  niti-ate-of-silver  solution  (grs. 
T-x  to  5  j  1  applied  to  the  inflamed  surfaces  by  means  of  a  camel's-hair 
brush.  The  excess  should  be  immediately  washed  away  by  the  free 
use  of  warm  water.  This  should  be  repeated  every  day  until  the  puru- 
lent discharge  is  notably  diminished.  Boracic-acid  water  fgrs.  v — 5j) 
should  be  used  several  times  each  day  after  the  application  of  the  nitrate 
of  silver. 

Croupous  conjunctititis  is  a  contagious  disease  met  with  in  children, 
and  characterized  by  injection  of  the  mucous  membrane,  swelling  of  the 
lids,  and  the  deposit  of  a  film  or  membrane  upon  the  conjunctiva. 


410  A  TEXT-BOOK   ON   SURGERY. 

The  treatment  consists  chiefly  in  frequent  washing  of  the  eye  with 
warm  boracic-acid  water  in  the  earlier  stages.  When  suppuration  super- 
venes, the  indications  are  the  same  as  for  purulent  ophthalmia. 

Diphtheritic  Conjunctimtis. — In  this  disease,  which  is  exceedingly 
contagious,  the  inflammatory  process  is  rapid  and  often  hopelessly  de- 
structive. The  lids  soon  become  greatly  swollen,  and  the  mucous  mem- 
branes are  glazed  over  with  a  tough,  closely  adherent  diphtheritic  mem- 
brane. The  period  of  infiltration  varies  from  six  to  ten  days,  and  is  fol- 
lowed by  the  stage  of  suppuration. 

Treatment. — The  immediate  danger  is  destruction  of  the  cornea,  the 
circulation  being  more  or  less  interfered  with  by  the  false  membrane. 
Since  all  pressure  should  be  eliminated,  in  extreme  cases  it  will  be  advisa- 
ble to  perform  canthoplasty .  Cold-water  dressings  should  be  employed 
in  the  early  stages.  Leeches  to  the  temples  are  advised.  When  suppu- 
ration ensues,  astringents  are  indicated. 

Pterygium  is  the  name  given  to  a  vascular  network  which  extends 
from  the  ocular  conjunctiva  on  to  the  cornea.  It  is  usually  situated  on 
the  inner  side,  less  frequently  on  the  outer  portion  of  the  globe.  It  is 
commonly  triangular  in  shape,  the  apex  encroaching  more  or  less  upon 
the  corneal  surface.  It  is  caused  by  constant  irritation  from  dust  or 
sand,  or  tine  particles  of  matter  floating  in  the  air,  and  is  therefore  chiefly 
met  with  in  sandy,  arid  regions. 

When  small  and  not  progressive,  it  is  advisable  not  to  interfere  with 
pterygium.  AVhen  it  is  growing  steadily,  it  should  be  tied  off  or  removed 
by  dissection.  For  the  first  method  the  pterygium  is  lifted  at  the  mar- 
gin of  the  cornea,  and  a  fine  silk  thread  carried  beneath  it  here.  A 
second  is  carried  beneath  the  base  of  the  mass  at  the  conjunctival  fold. 
The  ligatures  are  tied  and  cut  short.  In  a  few  days  they  come  away, 
and  the  vascular  tuft  disappears  ;  or  a  dull  in- 
strument, as  a  strabismus-hook,  may  be  insert- 
ed beneath  the  pterygium,  which  is  gradually 
detached  and  divided  with  the  scissors.  One 
or  two  sutures  are  inserted  to  close  the  wound, 
where  the  base  of  the  growth  is  cut  away  from 
Fio.  418B.  the  conjunctiva. 

Pinguecula.  (Swanzy.)  Pinguecula. — This  is  a  small,  yellow  eleva- 

tion occasionally  met  with  at  the  inner  or  outer 
margin  of  the  cornea  (Fig.  418  b).  It  occurs  usually  in  the  aged,  and 
should  not  be  molested  unless  it  seriously  interferes  with  vision  or 
comfort.     It  is  a  simple  hypertrophy  of  the  tissues  of  the  conjunctiva. 

Lupus  of  the  conjunctiva  is  exceedingly  rare,  and  does  not  require 
special  consideration. 

Epithelioma  here  does  not  differ  from  this  affection  on  otlier  mucous 
surfaces. 

Cystic  tumors  occur  in  the  conjunctiva  in  a  certain  j)roportion  of 
cases,  and  demand  extirpation. 

Polypus  develops  occasionally  on  the  semilunar  fold,  or  caruncula, 
and  should  be  clipped  off. 


THE   CONJUNCTIVA  AND   CORNEA. 


411 


LitJiiasis^  or  calcification  of  the  secretion  of  the  Meibomian  glands, 
appears  in  the  shape  of  little  white  spots  or  elevations  on  the  inner  sur- 
faces of  the  lids.  As  they  produce  considerable  irritation  of  the  conjunc- 
tiva and  cornea,  they  should  be  picked  out  vrith  a  needle-point  after 
anaesthesia  with  cocaine  is  secured. 

Xerosis  is  a  term  applied  to  a  dry  condition  of  the  conjunctiva  re- 
sulting from  changes  in  the  structure  of  this  membrane  and  deficient 
supply  of  the  secretions  which  moisten  this  surface.  The  indications  are 
to  remove,  if  possible,  any  chronic  inflammatory  condition,  and  keep  the 
eye  moist  by  artificial  means. 


Fio.  418  D. — Daniels'a  curette. 


CORKEA. 

Foreign  Bodies  and  Wounds. — Non-penetrating  wounds  of  the  cor- 
nea should  be  thoroughly  cleansed  with  warm  boracic-acid  solution,  and 
the  lids  closed  with  a  bandage  until  repair  is  effected.  A  penetrating 
wound  should  be  treated  on  the  same  principle  as  the  incision  for  cataract. 

A  foreign  body  lodged  upon  or  buried  in  the  cornea  should  be  at  once 
removed.  Ansesthesia  with  cocaine  is  essential.  Oblique  illumination 
by  means  of  the  convex  lens  is  of  value  in  locating  the  body.  A  clean 
needle  or  knife-point  may  be  used  in  lifting  the  foreign  substance  out. 


^^ 


Fia.  418  E. — Demarre's  retractors. 


Keratitis,  or  corneitis,  may  originate  from  injury  or  disease  of  the 
cornea  proper  or  by  extension  of  the  inflammatory  process  from  the 
conjunctiva  or  sclerotic,  iris  or  choroid.  The  symptoms  are  pain  vari- 
able in  character,  interference  with  vision,  especially  if  the  infiltration 
occurs  toward  the  center  of  the  cornea,  and  the  appearance  of  a  cloudy 
film  upon  the  normally  clear  and  transparent  membrane. 

Diffuse  idiopathic  keratitis  usually  commences  at  the  periphery  and 
travels  toward  the  center.  Occurring  as  a  feature  of  a  constitutional  dys- 
crasia  (syphilis,  tuberculosis,  etc.),  both  eyes  are  usually,  though  not 
simultaneously,  involved. 

Abscess  of  the  cornea  may  be  recognized  by  the  gi-ayish- yellow  color 
of  the  pus  collection  and  the  greater  density  of  the  membrane  at  this 
point.     In  many  cases  the  transudation  or  escape  of  the  purulent  liquid 


412  A  TEXT-BOOK  ON  SURGERY. 

takes  place  into  the  anterior  chamber,  and  may  be  seen  to  occupy  the 
lower  portion  of  this  space  {Jiypopyon). 

Treatment. — In  traumatic  heratitis  the  removal  of  all  irritation,  dis- 
infection with  warm  boracic-acid  solution,  relief  from  pain  by  cocaine 
locally  or  morphia  internally,  and  the  exclusion  of  light  by  the  dark 
room,  bandage,  or  shade,  are  the  indications. 

When  the  disease  is  secondary  to  inflammation  in  other  parts  of  the 
globe  or  conjunctiva,  the  treatment  should  be  directed  to  the  original 
malady  as  well  as  to  the  protection  of  .the  cornea. 

Diffuse  Jceratitis  demands  active  constitutional  treatment  to  increase 
nutrition  and  neutralize  the  virus  of  general  infection.  In  abscess,  ten- 
sion should  be  relieved  by  careful  puncture.  Penetration  of  the  anterior 
chamber  with  the  instrument  should  be  avoided,  unless  the  pus  here  is 
rapidly  increasing  ;  it  should  then  be  evacuated. 

Pannus  is  a  term  applied  to  a  condition  of  opacity  of  the  cornea  due 
to  the  formation  of  a  vascular  network  beneath  the  epithelial  covering  of 
this  membrane.  It  is  associated  with  a  conjunctivitis,  the  vessels  really 
extending  from  the  conjunctiva  into  the  cornea. 

If  the  disease  is  due  to  chronic  granular  lids,  entropion,  distichi- 
asis,  etc.,  the  cause  should  be  at  once  eliminated.  In  milder  cases  of 
persistent  pannus  a  cure  may  be  effected  by  excision  of  a  zone  of 
conjunctiva  and  subconjunctival  tissue  from 
around  the  cornea  (Nettleship).  In  severer 
cases  the  local  use  of  jequirity-bean  is  ad- 
vised. Prof.  David  Webster  recommends  the 
following : 

One  jequirity-bean  coarsely  powdered  is 
placed  in  an  ounce  of  water  for  four  hours. 
The  patient  is  then  required  to  bathe  the 
affected  eye  very  freely  with  this  solution  for 
ten  or  fifteen  minutes,  letting  some  of  it  get 
into  the  eye.  One  thorough  washing  will 
usually  produce  the  characteristic  membrane 
of  the  conjunctiva.  If  this  does  not  succeed, 
the  operation  should  be  repeated.  Or  the 
Fio.  419.  bean,  very  finely  pulverized,  may  be  applied 

to  the  whole  palpebral  conjunctiva. 
A  convenient  shade  or  screen  for  the  eye  is  shown  in  Fig.  419. 
Ulcus  CornecB. — Ulcers  of  the  cornea  may  follow  injury,  or  the  erup- 
tion of  herpes  or  small-pox ;  they  are  met  with  in  conditions  of  general 
malnutrition  (syphilis,  tuberculosis,  etc.),  and  may  also  occur  with  in- 
flammation of  the  other  structures  of  the  eyeball,  or  of  the  lids  or  con- 
junctiva. 

HeriDetic  vesicles  occur  at  times  upon  the  cornea,  either  as  herpes 
zoster  ophtludmicus  or  herpes  cornea:  fehrilis  (Swanzy).  They  appear 
as  groups  of  clear  vesicles,  the  superficial  covering  of  the  vesicle  giving 
way  within  a  few  hours  and  leaving  a  shallow  ulcer.  In  treatment, 
herpes,  or  the  resulting  ulcer,  demands  Little  beyond  protection  from 


THE   COXJUXCTR'A   AXD    CORNEA.  413 

Kgh.t,  the  removal  of  all  imtation  by  the  bandage,  and  the  prevention 
of  infection  by  careful  aseptic  irrigation. 

PJilyctenulce  of  the  Conjunctiva,  and  Cornea. — Phlyctenular  nlcers 
occur  almost  invariably  in  strumous  subjects,  either  with  or  without  any 
direct  exciting  cause.     When  first  noticed  they  are  usually  papules  or 
pustules  on  the  conjunctiva  or  cornea  or  both. 
There  is,   however,   a  localized  hyperfemia  in 
and  near  the  spots  where  the  elevation  occurs 
which  precedes  the  papule  or  pustule.     Break- 
ing down  and  discharging  their  contents,  nlcers 
of  variable  extent  are  formed.     They  fi'equent- 
ly  develop   on   the   conjunctiva   and   sclerotic 
without  invading  the  cornea.     J^ot  infrequent- 
ly, however,  the  process  of  ulceration  travels  Fig.  420. 

•' '  ,  ^      ,  „     ,  ,  Phlvctenula  of  the  conjunctiva 

on  and  toward  the  center  of  the  cornea,  leav-  'and  comea.   (Travers.) 

ing  behind  a  ti-ail  of  enlarged  vessels,  giving  to 

the  whole  a  comet-like  appearance  (Fig.  420).  Perforation  may  follow 
in  a  certain  proportion  of  cases.  These  ulcers  may  occur  in  all  ages,  but 
are  chiefly  met  with  after  the  thii-d  year  and  before  the  twenty-fifth 
year  of  life. 

Ulcus  Serpens. — The  acute  serpiginous  ulcer  is  probably  due  to  in- 
fection. It  commences  as  a  grayish  film  or  spot,  breaking  down  from  the 
center,  leaving  sharp,  precipitous  edges  (as  in  phagedenic  chancre),  ''  one 
part  of  which  is  more  densely  opaque  than  the  rest ;  this  infiltrated  ad- 
vancing edge  is  the  distinguishing  mark  of  the  ulcer  "  (Jfettleship). 

Treatment.— hi  phlyctenular  keratitis  and  conjunctivitis  warm  appli- 
cations of  boracic-acid  water  are  useful.  Pain  should  be  relieved  as 
heretofore  directed.  If  blepharospasm  is  present,  canthotorny  may  be 
necessaiy.  The  ulcers  should  be  stimulated  locally  by  use  of  nitrate  of 
silver  to  those  on  the  conjunctiva,  the  mitigated  stick ;  while  weaker 
solutions  (gr.  v-x,  3  j)  may  be  used  for  the  corneal  ulcers.  In  given  cases 
the  ulcers  may  be  scraped  out  or  burned  with  the  fine  galvano- cautery 
platinum  wire.  The  prevailing  dyscrasia  should  be  corrected  by  appro- 
priate remedies.  The  nutrition  should  be  increased,  and  an  out-of-door 
life  advised. 

In  acute  serpiginous  ulcer  active  measures  are  often  imperative,  the 
phagedenic  process  marching  rapidly  to  perforation  and  collapse  of  the 
globe.  Hot  boracic-acid  water  applications  at  intervals  of  an  hour  or 
two  are  advised  for  relief  of  pain.  Cocaine  may  also  be  instilled.  If  the 
ulcer  does  not  remain  stationary,  it  should  be  carefully  and  thoroughly 
burned  with  the  cautery  needle  upon  the  same  principle  as  for  chan- 
croidal ulcer  of  the  skin.  When  the  serpiginous  ulcer  dips  down  into 
the  deeper  corneal  tissue  and  undermines  it,  it  should  be  laid  open  by 
incision  in  its  entire  extent. 

StapJiylorna  Cor/ieffi.— Bulging  of  a  portion  of  the  corneal  surface 
may  result  from  intra-ocular  tension  upon  a  point  weakened  by  ulcera- 
tion or  cicatrization.  Conical  cornea  differs  from  this  in  being  due  to 
atrophic  (not  inflammatory)  changes  in  the  central  portion  of  the  cornea, 


414  A  TEXT-BOOK   ON  SURGERY, 

this  part  projecting  by  reason  of  intra-ocular  tension.  When  perfora- 
tion takes  place,  the  aqueous  humor  escapes  and  usually  carries  the  iris 
with  it,  this  latter  structure  being  caught  in  the  opening,  where  it  ad- 
heres.    This  condition  is  known  as  anterior  synechia. 

When  the  staphyloma  involves  a  limited  portion  of  the  cornea,  iridec- 
tomy should  be  done,  making  the  artificial  pupil  behind  the  best  remain- 
ing surface  of  the  cornea.  In  complete  staphyloma,  vision  being  lost, 
Critchett's  operation  is  advisable.  Five  half-curved  needles,  threaded 
with  fine  strong  silk,  are  passed  from  above  downward  through  the 
sclei-otic,  being  made  to  enter  and  exit  half-way  between  the  insertions 
of  the  recti  muscles  and  the  posterior  edge  of  the  staphyloma.     When 


A 


Fig.  421  — Needles  intioduced  in  Cntohett's  Fig.  4:21a. — The  same,  after  the  sutures  are 

operation  foi  btaphjloma      (Abadio )  tied.    (Swanzy.) 

the  point  of  each  needle  has  emerged  about  one  quarter  inch,  it  is  al- 
lowed to  remain,  and  the  staphyloma  is  divided  by  a  horizontal  incision. 
The  flaps  are  now  snipped  off  with  the  scissors  about  one  twelfth  inch 
in  front  of  the  needles,  this  line  (see  the  dotted  line.  Fig.  421)  being- 
through  the  sound  sclerotic.  The  needles  are  next  drawn  through  and 
the  sutures  tied,  as  in  Fig.  421  a. 

In  conical  cornea,  if  any  operative  interference  is  deemed  advisable, 
the  conicity  should  be  reduced  by  inducing  cicatrization  at  and  about  the 
apex  of  the  projection. 

Von  Graefe's  MetJiod. — Just  to  one  side  of  the  apex  of  the  cone  re- 
move with  the  knife  a  small  bit  of  the  surface  of  the  cornea  without 
penetrating  the  anterior  chamber.  Every  third  day  for  about  two  weeks 
this  wound  should  be  touched  with  the  mitigated  pencil  of  nitrate  of 
silver.  Then  puncture  through  this  scar  every  second  or  third  day  for 
one  week,  evacuating  at  each  puncture  the  aqueous  humor.  The  wound 
is  now  allowed  to  heal. 

Nebula,  macula,  and  leucoma,  are  terms  used  to  designate  degrees  of 
corneal  opacity — the  first  being  so  slight  as  to  be  scarcely  discernible, 
the  second  a  more  serious  lesion,  while  in  leucoma  the  opacity  is  com- 
plete. The  grayish  ring  seen  at  the  corneal  margin  in  many  old  persons 
— arcus  senilis — is  due  to  fatty  degeneration  of  the  cells  of  the  cornea, 
near  the  sclerotic  junction.  This  condition  occasionally  exists  in  the 
middle  aged  and  in  young  children.  While  not  a  contra-indication  to 
operative  interference,  that  it  suggests  faulty  nutrition  should  not  be 
forgotten  in  prognosis. 


SCLEROTIC— IRIS.  415 


Sclerotic. 


Simple  incised  wounds  of  tlie  sclerotic  heal  readily.  Lacerations  are 
more  serious  by  reason  of  the  greater  violence  accompanying  such  inju- 
ries.    No  special  treatment  is  demanded  beyond  rest  and  cleanliness. 

ScleriUs. — Inflammation  of  the  sclera  is  usually  circumscribed,  and 
may  or  not  be  accompanied  by  an  appreciable  thickening  of  this  tunic. 
■  As  a  rule,  the  affection  is  not  painful,  unless  it  extends  so  -n-idely  that 
the  choroid,  cornea,  or  iris  is  involved. 

Treatment  should  be  directed  to  the  prevailing  dyscrasia.  It  is  met 
with  as  a  late  manifestation  of  syphilis,  and  is  also  a  symptom  of  rheu- 
matism. ISTo  local  medication  is  advisable,  beyond  the  limited  instilla- 
tion of  atropine  to  prevent  iritis.  Rest,  and  light  cloths  wet  in  warm 
boracic-acid  solution  locally,  are  advised.  A  single  thorough  applica- 
tion of  the  actual  cautery  will  frequently  abort  this  disease,  which  under 
other  methods  of  treatment  usually  lasts  many  months. 

Iris. 

Iritis  is  most  frequently  seen  as  a  late  manifestation  of  syphilis  or 
in  chronic  rheumatism.  It  also  may  occur  with  inflammation  of  the 
cornea  or  sclera.  The  symptoms  are  abnormal  immobility,  thickening 
and  cloudiness  of  the  organ,  irregularity  of  the  pupillary  margin,  and 
adhesions  to  the  anterior  surface  of  the  capsule  of  the  lens  (posterior 
synechipe).  The  injected  zone  is  usually  of  a  pinkish  color.  Vision 
is  more  or  less  affected;  and  pain,  though  not  always  a  symptom,  is  usu- 
ally present.  In  rare  cases  the  pupil  is  occluded  by  the  formation  of  a 
membrane  from  the  products  of  inflammation. 

The  treatment  of  iritis  is  local  and  general.  To  prevent  permanent 
adhesions  and  to  relieve  pain,  the  instillation  of  atropine  solution — gi".  iv 
to  water  %  j — is  imperative.  From  one  to  two  minims  should  be  dropped 
in  the  conjunctival  sac  every  hour,  in  the  first  few  days  of  the  attack. 
The  degree  of  synechia  is  evident  as  soon  as  the  iris  is  affected  by  the 
atropine,  and  even  when  the  adhesions  between  the  capsule  of  the  lens 
and  the  iris  are  not  completely  relieved,  firmer  and  more  injurious  adhe- 
sions will  be  prevented.  Bloodletting  at  the  temples,  either  by  scarifica- 
tion and  cups,  or  dry  cupping,  hot  fomentations,  etc.,  are  local  remedies 
of  value.  Rest  to  the  eyes  should  be  complete,  and  exposure  to  draughts 
or  extreme  changes  in  temperature  are  to  be  avoided.  Any  constitu- 
tional disease  should  be  treated  or  any  diathesis  corrected  by  internal 
medication.  Saline  laxatives  are  indicated,  as  in  other  inflammatory 
affections. 

In  extreme  cases,  when  all  other  remedial  agents  fail,  iridectomy 
may  be  necessitated.  This  operation  will  be  described  hereafter.  The 
permanent  changes  to  which  the  iris  is  subject,  after  iritis,  are  adhe- 
sions (synecMcB),  atrophy  of  the  curtain  at  one  or  many  points  as  the 
effusion  disappears,  and  changes  in  color  due  to  absorption  of  the  nonnal 
pigment. 


416  A  TEXT-BOOK   ON   SURGERY. 

Choroid  and  Ciliary  Body. 

Choroiditis  is  occasionally  of  traumatic  origin.  The  lines  of  rupture 
are  seen  most  frequently  near  the  fundus,  and  in  recent  injuries  may  be 
concealed  by  extravasation.  IdiopatMc  choroiditis  occurs  often  in  the 
tertiary  step  of  syphilis.    A  less  frequent  variety  is  of  tuberculous  origin. 

The  diagnosis  rests  chiefly  upon  examinations  with  the  ophthalmo- 
scope. Disease  is  evident  from  the  abnormal  paleness  due  to  atrophy 
and  diminution  of  the  blood-supply.  It  may  be  general  and  symmetri- 
cal in  the  two  eyes  {syphilis),  or  confined  to  one  or  more  isolated  patches 
{tuberculosis).  In  the  syphilitic  variety,  changes  in  the  retina  are  more 
evident.  In  very  old  persons  an  extensive  area  of  atrophy  may  occasion- 
ally be  observed,  situated,  as  a  rule,  at  the  fundus. 

The  indications  in  treatment  are  to  correct  the  prevailing  dyscrasia, 
by  specific  remedies  and  tonics,  and  to  give  the  eye  as  comj)lete  rest  as 
possible. 

Cyclitis  occurs  rarely  except  as  in  conjunction  with  inflammation  of 
the  sclerotic  choroid  or  iris. 

Sympathetic  ophthalmitis  is  a  term  applied  to  inflammation  in  one 
eye,  followed  by  a  like  disturbance  in  and  threatened  destruction  of  the 
other.  It  is  very  apt  to  occur,  after  tratimatic  cyclitis,  from  a  pene- 
trating body.  Dislocation  of  the  lens,  iritis,  or  any  inflammatory  process, 
without  penetration,  and  the  entrance  of  air  or  a  foreign  substance,  may 
also  cause  this  form  of  ophthalmitis. 

The  invasion  from  one  eye  to  the  other  is  now  believed  to  be  by  means 
of  septic  bacteria  traveling  along  the  optic  nerve  and  chiasm.  When 
once  declared,  the  remedy  of  most  avail  is  enucleation  of  the  diseased 
eye.  It  is  important  that  this  operation  be  not  too  long  postponed.  The 
chief  difliculty  to  be  surmounted  is  to  determine  when  it  is  necessary  to 
operate.     The  following  rules  may  serve  as  a  guide  : 

When  a  penetrating  septic  body  has  entered  the  eye  and  destroyed 
vision,  it  would  be  wise  to  enucleate  even  before  iritis  and  cyclitis  are 
established,  and  if  these  symptoms  of  ophthalmitis  are  present,  operation 
is  imperative.  Enucleation  is  indicated  in  an  eye  in  which  a  foreign 
body  is  lodged  with  vision  not  materially  impaired  when  the  earliest 
symptoms  of  irido-cyclitis  supervene. 

Idiopathic  inflammation  of  the  interior  of  the  globe,  which  destroys 
vision,  also  indicates  enucleation. 

Operation. — Seize  the  conjunctiva  with  a  mouse- tooth  forceps  over  the 
location  of  the  internal  rectus,  open  the  sac  here,  introduce  the  strabis- 
mus-hook and  divide  the  internal  muscle  at  its  insertion  into  the  globe. 
The  conjunctiva  is  opened  in  the  direction  of  the  other  recti  muscles  until 
all  four  are  divided.  The  ball  is  then  carried  toward  the  nose  and  a  dull- 
pointed  scissors  curved  on  the  flat  is  carried  (concavity  to  the  globe) 
backward  and  the  nerve  divided  close  to  the  ball.  The  attachments  of 
the  oblique  muscles  are  next  cut  through. 

An  artificial  eye  should  not  be  worn  until  the  stump  is  entirely  healed, 
which  requires  usually  from  four  to  five  weeks. 


CHOEOID  AXD   CILIARY  BODY. 


417 


I 


Glaucoma. — This  disease  is  almost  always  met  witli  after  the  forti- 
eth year,  and  is  more  common  in  the  hypermetropic  than  in  the 
myopic  eye. 

The  prevailing  symptom  is  an  abnormal  distention  of  the  eyeball. 

Glaucoma  may  be  acute,  subacute,  or  chronic.  In  rare  instances,  it 
occurs  with  great  rapidity  {g.  fulniinans).  More  frequently  it  is  slower 
in  its  progress.  The  earliest  symptom  is  dimness  of  vision.  Patients 
usually  complain  of  indistinctness  of  sight,  as  if  they  were  looking 
through  frosted  glass.  These  attacks  are  at  first  commonly  spasmodic, 
but  the  interference  with  vision  soon  becomes  permanent.  Halos  or 
rainbows  are  seen  when  an  artificial  light  is  looked  at.  The  cornea  has 
a  dead  and  glazed  appearance,  and  the  ii-is  is  not  so  movable  as  normal. 
If  the  pulp  of  the  finger  is  pressed  upon  the  eyeball,  it  is  felt  to  be  hard 
and  abnormally  inelastic.  Pain  is  not  always  present.  Inflammation 
may  or  may  not  occur.  Blindness  sooner  or  later  supervenes,  unless  jire- 
vented  by  treatment.  The  causes  of  glaucoma  are,  as  yet,  not  satisfac- 
torily explained.  It  is  more  generally  held  that  obstruction  of  the 
efferent  lymph-channels,  or  of  the  vessels  which  carry  off  the  intravascu- 
lar fluids,  is  the  chief  cause  of  this  disease. 


Fig.  422  c. 
Curved  iris  scissors. 


Fig.  422  d. 
Drum  for  trying  the  edge  of  eye  instruments. 


Treatment.— T^Lia  chief  reliance  is  in  iridectomy.  With  the  iridec- 
tomy knife,  enter  the  anteiior  chamber  by  cutting  through  the  sclerotic 
near  the  corneal  border,  exposing  the  upper  margin  of  the  iiis  for  at 
least  one  fifth  of  its  cu-cumference.  Divide  the  iris  at  one  end  of  the 
incision  in  a  line  radiating  from  its  pupillary  margin  to  its  ciliary 
attachment,  by  traction  tear  it  fi-om  the  ciliary  attachment  and  divide 
27 


418  A  TEXT-BOOK  ON  SURGERY. 

with  the  scissors  at  the  other  limit,  severing  one  fifth  of  the  membrane 
(Fig.  423).     No  particle  of  iris  should  be  allowed  to  be  caught  and 
remain  in  the  wound.     The  after-treatment  consists 
in  bandaging  the  eye,  and  complete  rest. 

In  mild  cases,  a  smaller  section  of  the  iris  should 

be  made.     The  edge  may  be  drawn  out  with  the 

Fig  423— iridectom    for     ^o^'ceps  and  a  loop  of  iris  clipped  off  with  the 

glaucoma.    (De  WeckerO       SCisSOrS. 


Crystalline  Lens. 

Cataract,  or  opacity  of  the  lens,  although  chiefly  encountered  after 
the  fortieth  year  of  age,  may  occur  at  any  period  of  life.  It  may  be 
divided  into — 1,  congenital  or  infantile  cataract ;  2,  cataract  of  adult 
and  middle  life  (before  forty) ;  3,  senile  cataract. 

Cataracts  are  also  classified  according  to  their  location  in  the  lens — 
nuclear,  or  central ;  cortical,  or  peripheral ;  and  capsular. 

Nuclear  cataract  occupies  the  center  of  the  lens,  either  permanently, 
or  spreads  gradually  vmtil  the  organ  is  entirely  involved.  It  is  at  first 
observed  as  an  opacity  or  cloudiness  immediately  behind  the  pupil,  white 
or  amber-brown  in  color. 

Cortical  cataract  com.mences  near  the  margin  of  the  lens,  behind  the 
iris,  and  is  characterized  by  grayish-white  lines  or  streaks  projected 
toward  the  center  of  the  pupil. 

In  the  capsular  variety  the  cloudiness  or  opacity  is  confined  to  the 
anterior  shell  of  the  capsule,  the  substance  of  the  lens  not  being  affected. 

Cataracts  which  are  congenital,  or  only  observed  in  eai'ly  infancy,  are 
classified  as  anterior  polar,  or  pyramidal ;  lamellar,  or  zonular ;  cen- 
tral, posterior  polar,  and  fusiform.  All  of  these  types  are  compara- 
tively rare. 

The  anterior  polar  variety  is  due  to  the  formation  of  a  chalky  concre- 
tion in  the  center  of  the  anterior  lamellse  of  the  lens,  caused  by  infiam- 
mation  and  perforating  ulcer  of  the  cornea  in  the  early  days  of  life. 
Operative  interference  is  not  called  for. 

In  lamellar  or  zonular  cataract  the  opacity  is  limited  to  a  thin  layer 
of  lens-substance,  about  half  way  between  the  nucleus  and  the  anterior 
and  posterior  surfaces.  The  nucleus  and  peripheral  portions  are  normal. 
When  vision  is  seriously  interfered  with  by  this  form  of  opacity,  it 
may  be  improved  by  iridectomy  or  incision  through  the  anterior  layer 
of  the  capsule  {discission).     In  some  cases  extraction  is  advisable. 

In  central  cataract  the  deeper  fibers  of  the  lens  only  become  opaque. 
It  may  be  treated  in  the  same  way  as  the  zoQular  opacity.  Posterior 
polar  cataract  is  seen  deeply  behind  the  center  of  the  lens.  Operative 
treatment  is  rarely  demanded,  and  when  indicated  discission  is  advised. 

Fusiform  opacity  extends  from  the  posterior  to  the  anterior  pole.  It 
is  very  rare. 

Cataracts  are  primary  when  the  opacity  is  developed  independent  of 
any  other  lesion  of  the  eye,  and  secondary  when  some  other  lesion  exists. 


CRYSTALLINE  LENS.  419 

A  traumatic  cataract  occurs  as  a  result  of  rupture  of  the  capsule,  with 
or  without  perforation,  allowing  the  aqueons  humor  to  invade  the  crys- 
talline substance.  A  Morgagnian  cataract  is  one  in  which  partial  lique- 
faction of  the  cortex  has  taken  place,  and  the  nucleus  drojjs  to  the  lowest 
portion  of  the  capsule.  The  opacity  occurring  in  dlahetes  mellitus  is 
called  diabetic  cataract. 

Cataracts  are  also  termed  senile,  hard,  and  soft.  Senile  cataract  oc- 
curs, as  its  name  implies,  in  old  persons,  usually  very  late  in  life,  but  not 
unfrequently  as  young  as  the  fortieth  year.  This  variety,  though  usually 
firm  or  hard,  is  at  times  soft.  Under  forty  years  cataracts  are  usually 
soft.  A  cataract  is  said  to  be  "ripe"  when  the  lens  is  solidified  to  such 
an  extent  that  all  of  it  may  be  extracted. 

Symptoms  and  Dia.gnosis. — With  senile  cataract  the  earlier  symp- 
toms are  disturbance  of  vision.  Indistinctness  of  vision  for  distant  ob- 
jects is  usually  first  noticed,  and,  in  certain  cases,  multiple  images  of  one 
object  are  observed.  If  the  cataract  is  nuclear  or  central,  vision  is  im- 
proved by  shading  the  eye,  thus  allowing  the  pupil  to  dilate.  In  corticcd 
cataract  this  is  not  the  case,  but  by  dilatation  of  the  pupil  with  atropine 
the  presence  of  the  perijjheral  opacity  may  be  detected.  When  a  cata- 
ract is  general  and  ripe,  blindness  for  objects  is  complete,  although  light 
and  darkness  are  appreciable. 

Examined  in  ordinary  light  a  well-marked  nuclear  cataract  may  be 
recognized ;  but  it  is  by  focal  illumination  and  by  the  ophthalmoscope 
that  a  diagnosis  is  positively  made.     The  pupil  should  be  dilated. 

A  large  nucleus  with  very  fine  radiating  striae  indicates  a  hard  cata- 
ract, while  a  small  nucleus  and  large  strise  suggest  a  soft  opacity.  If  the 
cataract  be  riije,  no  clear  space  will  be  discovered  between  the  nucleus 
and  the  iris,  and  no  shadow  wiU  be  thrown  upon  the  nucleus  by  the  iris. 
Focal  (oblique)  illumination — i.  e.  concentrating  by  means  of  a  prism  the 
rays  of  a  strong  light  let  fall  obliquely  upon  the  cornea — is  essential  in 
this  examination.  By  the  ophthalmoscope  the  normal  red  reflection  from 
the  fundus  is  absent  (Swanzy). 

As  it  is  important  toTiave  a  cataract  ripe  when  an  operation  is  under- 
taken, Foster  submits  the  following  general  guide  :  Cataracts  which  are 
ripe,  according  to  the  tests  just  given,  and  in  which  there  are  no  sectors 
shining  like  motJier -of -pearl,  are  considered  ripe  for  operation.  In  color 
they  are  white,  yellow,  or  gray  ;  also  when  the  lens  is  wholly  occupied 
with  a  brownish-yellow  nucleus.  This  may  be  semi-transpiarent,  and  the 
iris  throw  a  distinct  shadow. 

Treatment.— Whf^in  a  cataract  is  not  ready  for  operation,  the  vision 
may  be  improved  by  glasses,  which  shade  the  eyes,  allowing  the  pupil  to 
dilate,  and  by  the  instillation  of  weak  ati-opine  solution.  These  measures 
apply  to  opacities  at  or  near  the  antero-posterior  axis  of  the  lens. 
■  Opacities  of  the  lens  may  be  removed  by  three  methods  :  Solid  extrac- 
tion, absorption  after  discission,  and  suctioii.  The  first  method  is  ap- 
plicable to  all  forms  of  ripe  cataract ;  the  lamellar,  central,  posterior 
polar,  and  fusiform  varieties  are  treated  by  discission  when  any  opera- 
tive interference  is  indicated ;  soft  opacities  are  removable  by  suction. 


420 


A  TEXT-BOOK   ON   SURGERY. 


Extraction,  except  for  appearance'  sake,  is  not  indicated  when  only- 
one  lens  is  affected,  vision  being  about  perfect  in  the  other,  unless  the 
cataract  is  becoming  overripe.  It  is  advisable  to  remove  only  one  lens 
at  a  single  operation,  even  in  double  ripe  cataract. 

Operation  is  not  advisable  when  any  serious  intra-ocular  complication 
exists,  or  when  insurmountable  opacity  of  the  cornea  is  jjresent.  It  is 
always  advisable  to  allay  any  existing  inflammation  of  the  ball  or  ap- 
pendages before  an  operation  for  cataract.  When  a  cataract  is  not  ripe, 
its  solidification  may  be  hastened  by  massage  of  the  globe — that  is,  by 
pressure  applied  over  the  ball  with  the  tips  of  the  fingers.  The  massage 
should  last  a  few  minutes,  and  be  repeated  every  few  days  as  indicated. 

Operation  of  Extraction. — Two  principal  methods  of  extraction  are 
at  present  employed,  viz.,  (1)  simple  extraction  and  (2)  extraction  after 
iridectomy.  The  former  is  the  ideal  operation,  and,  although  at  this 
date  not  so  generally  employed,  is  fast  gaining  in  popularity. 


Fig.  424. — Graefe's  speculum. 

Simple  Extraction. — The  most  careful  asepsis  is  demanded.  The  eye 
should  be  irrigated  with  warm  boracic-acid  solution  (gr.  x-xv  to  §j). 
The  instruments  should  be  thoroughly  cleansed  by  boiling  and  immer- 
sion in  alcohol.  Anseslhesia  is  obtained  by  dropping  several  minims  of 
2-per-cent  cocaine  hydrochlorate  into  the  eye,  five  minutes,  and  again 
three  minutes,  before  the  operation.     The  head  should  be  so  held  that 


Fig.  424  a. — Graefe's  fixation  forceps. 

the  cocaine  rests  in  contact  with  the  upper  surface  of  the  cornea  through 
which  the  incision  is  made.  When  ready  to  operate,  the  eye  and  con- 
junctival sac  should  be  dried  with  absorbent  boracic-acid  cotton  ]3ellets. 
The  speculum  is  introduced  and  secured,  and  the  conjunctiva  seized 
with  fixation-forceps  just  below  the  center  of  the  lower  margin  of  the 
cornea.     The  ball  is  drawn  slightly  downward  and  steadied,  while  the 


Fig.  424  b. — Graefe's  linear  tnife. 


knife,  cutting  edge  upward,  is  entered  through  the  cornea  just  at  the 
corneo-sclerotic  junction,  carried  carefully  across  in  fi'ont  of  the  iris, 
which  must  not  be  touched,  and  out  at  a  jDoint  corresponding  to  that 
of  entrance   (Fig.  424  c).      By  careful   to-and-fro  movements,  the  flap 


EXTRACTIOK 


421 


is  made  by  cutting  upward  througli  the  cornea  just  anterior  to  the 
sclerotic  Junction.  The  line  between  the  angles  of  this  flap  should 
cross  the  cornea  a  little  more  than 
one  third  the  distance  from  the  up- 
per to  the  lower  margin.  As  this 
section  is  being  made,  and  before 
the  aqueous  humor  escapes,  an  as- 
sistant should  slightly  lift  the  spec- 
ulum, so  that  no  pressure  may  be 
made  by  it  upon  the  ball. 

The  cystotome  is  now  carried 
through  the  wound,  kept  clear  of 
the  iris  by  the  operator,  who  very 
cautiously  scratches  through  the  an- 
terior capsule,  through  the  whole 
width  of  the  pupil.  Care  must  be 
taken  not  to  press  so  hard  against  the  lens  as  to  dislocate  it.  As  soon 
as  the  capsule  is  opened,  gentle  pressure  in  an  upward  direction  should 
be  exercised  by  means  of  the  spoon  against  the  lower  margin  of  the  cor- 
nea, or  pressure  with  the  fiager  on  the  lower  lid  may  suffice  to  deliver  the 


Fig.  424  0  — Introrluction  of  Gracfe's  knife,  show- 
inij  size  of  corneal  ilap  in  extraction  of  cata- 
ract.    (Swanzy.) 


Fig.  424  D. — Cystotome  and  Daviels's  spoon. 

lens  through  the  pupil  and  out  through  the  wound  of  incision.  The 
pressure  should  be  carefully  gauged  to  effect  only  the  exit  of  the  cataract, 
and  not  to  rupture  the  zonula.  The  wound  should  now  be  examined,  and 
no  particle  of  iris,  lens,  or  capsule  should  be  left  in  the  incision.  A  drop 
of  eserine  solution  (gr.  ij-3  j)  is  now  instilled  into  the  conjunctival  sac  in 
order  to  contract  the  pupil.  The  eye  is  finally  irrigated  with  the  boracic- 
acid  solution  and  the  dressing  applied,  and  both  eyes  closed  by  bandaging. 
The  patient  is  required  to  remain  quiet  in  a  light  room  for  a  week.  The 
first  change  of  dressing  should  be  made  on  the  second  day,  and  daily 
thereafter.  Strict  asepsis  is  essential  at  each  change  of  dressing.  The 
light  should  be  excluded  only  from  the  eyes  by  bandages  and  shades,  and 
not  from  the  room.  At  the  end  of  a  week  'or  ten  days  a  black  silk  shade 
may  be  substituted  for  the  bandages,  and  in  from  two  to  three  weeks  the 
patient  will  need  only  medium  smoke  coquilles  to  protect  his  eyes  from 
the  strong  light.  He  should  not  be  fitted  with  cataract  glasses  until  all 
signs  of  redness  and  sensitiveness  have  disappeared. 

Extraction  with  Iridectomy. — The  speculum  is  introduced  and  se- 
cured, and  the  ball  steadied  by  grasping  a  fold  of  the  conjunctiva,  just 
below  the  center  of  the  lower  mtirgin  of  the  cornea  (Fig.  424  c),  with  a 
mouse-tooth  fixation-forceps.  The  ball  is  drawn  slightly  downward,  and 
the  Von  Graefe  knife,  edge  upward,  is  made  to  enter  the  cornea,  just  at 
the  sclerotic  junction,  at  a  point  three  milimetres  (about  one  eighth  of 
an  inch)  below  the  highest  margin  of  the  cornea  (or  about  one  third  of 
the  distance  between  the  upper  and  lower  margins  of  the  cornea).     The 


422  A  TEXT-BOOK   ON   SURGERY. 

point  is  then  made  to  emerge  accurately  opposite  the  entrance,  when,  by 
a  gentle  movement  of  the  knife,  the  flap  is  completed  by  cutting  through 
the  cornea,  just  anterior  to  its  junction  with  the  sclerotic.  As  this  flap  is 
made,  a  certain  proportion  of  the  aqueous  humor  escapes.  The  fixation- 
forceps  being,  at  this  stage,  transferred  to  an  assistant,  the  ii'is-forceps 
are  introduced,  and  the  iris  seized  at  a  point  corresponding  to  the  center 
of  the  incision,  and  carefully  drawn  out  through  the  wound.  A  narrow 
strip,  including  the  entire  depth  of  the  iris,  is  then  excised. 

As  soon  as  the  iridectomy  is  completed  the  operator  relieves  the  assist- 
ant of  the  fixation- forceps,  directs  that  the  speculum  be  lifted,  so  that  no 
pressure  is  made  on  the  eyeball,  while,  with  the  cystotome  carried  into 
the  anterior  chamber,  he  freely  scratches  through  the  anterior  layer  of 
the  capsule.  Care  must  be  taken  not  to  press  so  hard  against  the  lens  as 
to  dislocate  it.  It  is  also  important  to  see  that  no  shred  of  the  capsule 
is  dragged  out  into  the  wound  in  withdrawing  this  instrument.  The 
globe  should  now  be  depressed,  either  with  the  forceps  or  by  the  patient's 
volition,  and  the  cataract  extracted  by  gentle  pressure  with  the  spoon 
from  the  lower  margin  of  the  cornea  upward.  The  pre&sure  should  be 
carefully  gauged,  and  the  wound  examined  as  above  described.  Should 
bleeding  occui',  this  may  be  checked  by  a  light  compress  of  cold  boracic 
solution.     The  affer- treatment  is  the  same  as  just  given. 

If  the  primary  incision  should  not  be  large  enough  to  allow  the  easy 
escape  of  the  lens,  it  should  be  enlarged,  preferably  with  the  iris-scissors  ; 
it  should  be  free,  to  begin  with.  If  any  fragments  of  the  lens  adhere  to 
the  capsule  or  are  caught  in  the  wound,  they  must  be  worked  out  by 
careful  manipulation.  Should  the  zonula  be  ruptured,  allowing  the  vit- 
reous to  escape,  the  lens  should  be  extracted  with  the  scoop.  The  vitre- 
ous should  be  divided  with  the  scissors  at  the  level  of  the  wound. 

Should  septic  infection  occur,  suppuration  of  the  wound  follows,  witli 
usually  desti'uction  of  the  eye.  The  treatment  should  be  frequent  irriga- 
tion with  boracic-acid  solution,  and  the  galvano-cautery  wire  applied  to 
the  margins  of  the  wound.  When  iritis  is  precipitated,  atropine  should 
be  instilled  and  warm  boracic-acid  water  dressings  applied. 

Strong  convex  glasses  are  necessary  after  the  operation,  but  the  eyes 
should  not  be  used  for  reading,  etc.,  for  three  or  four  months.  Two 
pairs  of  glasses  should  be  prescribed — one  for  reading  and  another 
for  vision. 

Discission. — After  dilatation  with  atropine,  ether  or  chloroform 
should  be  administered  to  prevent  any  movement  which  might  displace 
the  lens,  the  speculum  introduced,  and  the  field  of  operation  ren- 
dered aseptic. 


Fio.  425.— Beers'a  straight  needle. 

The  point  of  the  cataract-needle  is  made  to  pass  through  the  cornea 
near  the  outer  margin,  and  the  point  carried  to  the  center  of  the  pupil, 
where  it  enters  the  capsule  of  the  lens  (Fig.  425  a).     The  capsule  and  the 


THE  VITREOUS.— THE  RETINA.  423 

anterior  superficial  layers  of  the  lens  are  torn  open  by  gentle  move- 
ments of  tlie  point  of  the  instrument,  which  is  then  withdrawn,  being 
careful  not  to  injure  the  iris.     The  pupil  should  be  kept  fully  dilated, 
renewing  the  instillation  every  few  hours, 
if  necessary,  for  several  days.     Cold  ap- 
plications and  a  dark  room  are  the  chief 
indications    in    the    after-treatment.     If 
successful,  the  lens  becomes  opaque  after 
a  week  or  more,   and  gradually  disap- 
pears by  absorption.     A  second  operation 
may  be  necessary. 

Suction. — Dilate  with  atropine,  admin- 
ister ether,  incise  the  cornea  half-way 
between  its  center  and  margin,  perform 

-,.      .      .  n     ■    J.       T  J.-U  1  i>         Fio-  425  A.— Introduction  of  the  needle 

discission,   and  introduce   the  nozzle  of  in  discission.   (Swanzy.) 

the  syringe  into  the  lens,  when  it  and 

the  capsule  are  broken  up.  The  softened  lens  is  sucked  into  the  cylin- 
der by  steady  and  gradual  traction  on  the  piston.  Strict  asepsis  is 
essential.  A  single  introduction  of  the  instrument  is  advisable.  The 
after-treatment  is  the  same  as  for  discission. 


The  Vitreous. 

Hyalitis,  or  inflammation  of  the  vitreous,  may  result  from  trauma- 
tism, with  or  without  the  presence  of  a  foreign  body,  or  by  the  exten- 
sion of  some  idiopathic  inflammatory  process  from  the  choroid,  iris, 
on  any  portion  of  the  globe.  Syphilitic  choroiditis  is  especially  apt  to 
produce  hyalitis.  The  immediate  symptom  is  opacity  due  to  extravasa- 
tion of  blood,  or  the  exudation  of  the  products  of  inflammation.  The 
vitreous  breaks  down,  becoming  more  fluid  than  normal  {syncMsis). 
Flakes  or  small  collections  of  more  solid  matter  may  be  seen  to  change 
position  as  the  position  of  the  globe  is  changed.  "  Spots  before  the 
eyes"  {miisccB  volitantes)  occur  chiefly  in  myopic  subjects,  and  are  due 
to  changes  in  the  vitreous. 

The  exact  condition  of  the  vitreous  can  usually  be  made  out  by  care- 
ful examination  with  the  ophthalmoscope. 

Foreign  bodies,  when  composed  of  small  bits  of  metal,  may  be  removed 
by  the  electro-magnet.  Should  the  wound  in  the  sclerotic  be  not  suffi- 
cient, it  should  be  enlarged  and  the  middle  of  the  magnet  carried  into  the 
vitreous.  The  metal,  if  not  impacted,  adheres  to  the  magnet  and  is  with- 
drawn. When  the  foreign  body  is  non-metallic,  operative  interference  is 
of  doubtful  propriety  unless  general  inflammation  is  taking  place.  Idio- 
pathic hyalitis  should  be  treated  by  rest  to  the  eye  and  by  special  medi- 
cation. 

The  Retina. 

Inflammation  of  the  retina  {retinitis)  may  occur  independently  of 
lesion  of  any  other  portion  of  the  eye,  or  it  may  be  part  of  an  inflam- 


424:  A  TEXT-BOOK   ON  SURGERY. 

mation  of  the  choroid,  ciliary  body,  iris,  vitreous,  or  by  extension  from 
the  optic  nerve.  It  is  not  uncommon  in  syphilis,  and  follows  thrombosis 
and  embolism  of  the  vessels.  It  is  met  with  in  nephritis  and  in  severe 
cerebral  hyperemia. 

Detachment  of  the  retina  from  the  choroid  may  be  due  to  extravasa- 
tion of  blood  or  transudation  of  serum. 

All  these  conditions  may  be  determined  by  a  careful  analysis  of  the 
symptoms  present  and  by  ophthalmoscopic  examination.  The  indica- 
tions in  treatment  are  chiefly  to  correct  the  general  condition  of  disease 
on  which  the  retinitis  depends.  When  of  traumatic  origin,  the  chief 
reliance  is  vipon  complete  rest  and  warm  fomentations.  In  certain  mor- 
bid conditions  of  the  external  portions  of  the  retina,  objects  appear 
unusually  small  {micropsia).  The  opposite  of  this  condition  is  known 
as  megalopsia. 

Night-blindness  {hemeralopia)  is  usually  only  a  symptom  of  retinitis 
pigmentosa,  but  sometimes  occurs  in  other  diseases  of  the  retina  and 
optic  nerve. 

Day-blindness  {nyctalopia)  is  generally  due  to  exposure  to  strong 
light,  as  the  glare  of  the  ocean  in  the  tropics,  and  may  occur  in  persons 
of  faulty  nutrition. 

Optic  Neuritis. — The  optic  nerve  is  at  times  the  seat  of  neuritis 
which  may  originate  here,  or  descend  from  the  brain  along  the  nerve  ;  it 
may  be  secondary  to  retinitis,  or  become  involved  by  contact  with  morbid 
changes  occurring  in  the  lymph  spaces  and  other  tissues  contiguous  to  it. 
The  subjective  symptoms  are  varying  degrees  of  interference  with  vision. 
Amblyopia  (dimness  of  sight),  or  amaurosis  (complete  blindness),  may 
be  present.  These  symptoms  may  be  present  without  perceptible  change 
in  the  appearance  of  the  retina  or  optic  papilla.  When  the  lesion  is  be- 
yond the  disk,  atrophic  or  other  changes  of  the  papilla  may  be  recognized 
by  the  ophthalmoscope. 

In  some  instances  the  obliteration  of  the  retinal  image  is  confined  to  a 
portion  of  the  field  of  vision,  usually  one  half  {hemianopsia).  If  one  eye 
only  is  involved,  the  lesion  is  peripheral  and  limited  to  the  nerve  or 
retina  of  the  affected  eye.  If  binocular,  the  lesion  is  in  or  posterior  to  the 
optic  chiasm.  The  inner  half  of  one  and  the  outer  half  of  the  other  eye 
are  usually  obscured. 

Color -Blindness. — There  is  a  congenital  defect  of  the  retina  in  which 
the  individual  is  incapable  of  recognizing  certain  colors,  as  red,  green, 
and  blue  ;  a  little  more  than  three  per  cent  of  males  are  so  affected.  Of 
thirteen  hundred  and  eighty-three  men  in  the  employment  of  the  Penn- 
sylvania Railroad  Company  examined  by  Dr.  William  Thomson,  fifty- 
five  were  absolutely  color-blind.  It  is  less  common  in  women.  The 
usual  method  of  testing  is  that  with  Professor  Holmgren's  colored  wool- 
en threads.  If  the  patient  is  wholly  color-blind,  he  vnll  be  unable  to 
differentiate  between  the  principal  colors.  Partial  color-blindness  may 
be  detected  by  a  careful  test  with  the  woolen  threads,  requiring  the 
suspected  person  to  match  to  the  leading  colors  those  which  to  him 
appear  of  the  same  or  nearly  the  same  shades. 


STRABISMUS. 


425 


Strabismus. 

Strabismus,  or  "squint,"  may  be  convergent  or  divergent.  The  for- 
mer is  by  far  the  more  frequent  variety,  and  is  usually  observed  in  young 
children.  It  results  from  a  loss  of  the  noi-mal  equilibrium  in  the  mus- 
cles of  the  eye,  and  -n-hen  first  noticed  is  often  intermitteut,  appearing  in 
one  eye  and  then  the  other  {alternating).  As  a  result  of  prolonged  and 
repeated  efforts  at  accommodation  (contraction  of  the  ciliary  muscle 
causing  relaxation  of  the  zonula, 
with  consequent  increase  in  the 
antero-posterior  diameter  of  the 
lens),  the  internal  rectus  becomes 
permanently  shortened. 

The  degree  of  convergence  may 
be  determined  by  the  strabis- 
mometer  (Fig.  426).  Let  the  pa- 
tient fix  his  vision  on  a  distant  point  directly  in  front  of  him  ;  place 
the  center  of  the  instrument  directly  beneath  the  center  of  the  pupil, 
and  measure  the  distance  from  this  point  to  the  inner  angle  of  the  eye. 
The  same  measurement  on  the  affected  side  Avill  determine  the  degree  of 
convergence  on  that  side. 

Treatment. — Tenotomy  is  indicated  in  convergent  strabismus  for  the 
relief  of  deformity,  as  well  as  for  the  coiTection  of  vision.  The  prospect 
of  a  perfect  result  is  better  in  recent  cases  than  in  those  of  long  standing, 
in  which  the  external  rectus  has  been  overstretched  and  permanently 
weakened.     In  children,  about  the  seventh  year  is  the  best  period  for 


Fig.  426. — Lawrence's  strabismometer. 


Fig.  426  a. — Graefe's  strabismus  liook. 

operation.  Tenotomy  of  the  internal  rectus  is  thus  done :  The  conjunc- 
tiva is  first  anaesthetized  with  cocaine  solution,  and  two  to  four  minims 
may  be  injected  into  and  beneath  the  conjunctiva,  immediately  about 
the  insertion  of  the  muscle.  The  speculum  is  introduced,  and  the  con- 
junctiva, Just  on  the  inner  side  of  the  eye,  picked  up  with  the  forceps 
and  divided  with  the  scis- 
sors. The  strabismus- 
hook  (Fig.  426  a)  is  next 
carried  into  this  opening 
and  guided  beneath  and 
behind  the  tendon  of  the 
rectus  internus,  which  is 
pulled  forward  and  di- 
vided at  its  insertion 
into  the    sclerotic.     The 

hook  should  be  again  introduced,  to  make  sure  that  a  thorough  division 
is  effected.     A  pad  of  cotton  dipped  in  boracic-acid  solution,  held  in 


Fig.  426  b. — Strabismus  scissors. 


426  A  TEXT-BOOK   ON   SURGERY. 

place  by  a  dry  cotton  compress  and  bandage,  should  be  worn  for  one  or 
two  days.  When  strabismus  makes  its  apijearance  in  adult  life,  it  is 
usually  due  to  paralysis,  partial  or  complete,  of  one  or  more  of  the 
orbital  muscles.  The  lesion  producing  paralysis  may  be  situated  in  the 
brain  or  in  the  orbit.  Disease  of  the  bones  about  the  foramina  of  exit 
of  the  nerves  which  supjjly  these  muscles,  the  presence  of  syphilitic 
gummata,  or  any  neoplasm,  will  produce,  by  pressure  on  the  nerves  or 
muscles,  a  more  or  less  complete  paralysis.  Rheumatism  is  occasion- 
ally a  cause  of  strabismus. 

In  the  treatment  of  strabismus  due  to  paralysis,  operative  interfer- 
ence is  not  indicated  until  all  other  remedial  agents  have  been  exhausted 
in  vain.  When  operation  is  demanded,  not  only  should  division  of  the 
contracted  muscle  be  effected  as  Just  described,  but  the  weaker  muscle 
may  be  shortened  by  advancing  its  insertion. 

Take,  for  example,  the  external  rectus.  Perform  tenotomy  as  here- 
tofore described.  A  small  curved  needle  is  threaded  with  fine  silk  and 
carried  from  the  ocular  side  out  through  the 
divided  muscle  and  the  conjunctiva.  Each 
end  of  this  double  suture  is  now  threaded  to 
a  curved  needle  and  passed  beneath  and 
through  the  conjunctiva,  coming  out  near  the 
margin  of  the  cornea  and  about  one  eighth  of 
an  inch  from  the  vertical  meridian  of  the  eye 
above  and  below  (Fig.  426  c).  The  needles 
are  ciit  away,  and  the  two  ends  of  the  lower 
threads  tied  together,  at  the  same  time  that 
an  assistant  ties  the  upper  ends.  These  sut- 
ures are  allowed  to  remain  about  forty-eight 
hours.  The  amount  of  shortening  in  the  mus- 
Fio.  426  c-Advancement  of  the  ^^^  advauced  cau  bo  increased  by  carrying  the 
rectus.   (De  Wecker.)  first  needle  farther  back  through  the  muscle. 

In  order  to  get  the  best  possible  result,  the 
shortening  should  be  slightly  more  than  appears  necessary  at  the  time 
of  operation. 

Refraction. — The  Ophthalmoscope.* 

By  the  refraction  of  the  eye  we  mean  its  power,  when  in  a  state  of 
rest,  of  bringing  parallel  rays  of  light  to  a  focus.  In  normal  refraction, 
or  emmetropia,  the  focus  for  parallel  rays  is  upon  the  retina  (Fig.  427). 
When  the  focus  for  parallel  rays  is  not  on  the  retina,  there  is  said  to  be 
an  error  of  refraction.  The  term  ametropia  includes  all  the  errors  of 
refraction.  The  principal  forms  of  ametropia  are  :  1,  myopia  ;  2,  hyper- 
metropia.  All  the  other  forms  of  ametropia  are  included  under  the  head 
of  astigmatism,  in  which  the  refraction  differs,  in  degree  or  kind,  in 
opposite  meridians  of  the  same  eye. 

*  The  author  desires  to  acknowledge  his  indebtedness  to  his  friend,  Prof.  David  Webster, 
M.  D.,  by  whom  this  article  on  Eefraction  was  written. 


REFRACTIOX.— THE   OPHTHALMOSCOPE.  427 

The  difference  in   refraction  of  eyes  is  due  to   their  difference  in 
shajje.     While  the  emmetropic  eye  is  nearly  spherical,  the  myopic  eye 


Flo.  427. — Showing  concentratioQ  of  rays  of  light  (<7,  I,  c)  on  the  retina  (<i )  in  normal  refraction. 

(Swanzy.) 

is  egg-shaped — too  long  in  its  antero-posterior  diameter  ;  and  the  hyper- 
metropic eye  turnip-shaped — too  short  in  its  antero-posterior  diameter. 
Thus,  while  the  principal  focus  of  the  emmetropic  eye  is  upon  the  retina, 


Fig.  427  a. — Showing  rays  converging  to  focus  (at  a)  behind  the  retina  {b,  c).    The  hypermetropic  eye. 

(Swanzy.) 

that  of  the  hypermetropic  eye  is  behind  the  retina  (Fig.  427  a),  and  that 
of  the  myopic  eye  in  front  of  it  (Fig.  427  b). 


Fig.  427  e. — Showing  concentration  at  (/)  of  rays  of  light  ('j,  i)  in  front  of  retina  (<•,  d)  in  myopia. 

iSwanzy.) 

Astigmatism  is  usually  due  to  asymmetry,  or  irregularity  of  sur- 
face, of  the  cornea,  probably  sometimes  to  a  like  condition  of  the  lens. 
The  varieties  of  astigmatism  are  six  in  number :  1,  simple  myopic ; 
2,  compound  myopic;  3,  simple  Tiypermefropic ;  4,  compound  Tiyper- 
metropic ;  5,  mixed ;  and,  6,  irregular  astigmatism. 

In  simple  myopic  and  simple  hypermetropic  astigmatism,  the  princi- 
pal focus  of  one  meridian  of  the  cornea  is  upon  the  retina,  while  the 
principal  focus  of  the  opposite  meridian  is  anterior  to  the  retina  or  be- 
hind it.  accordingly  as  the  astigmatism  is  myopic  or  hypermetropic. 

In  compound  myopic  astigmatism  all  the  meridians  of  the  eye  are 


428  A  TEXT-BOOK  ON   SURGERY. 

myopic,  but  one  of  them  more  so  than  any  of  the  others,  and  the  merid- 
ian at  right  angles  to  it  less  so  than  any  of  the  others. 

In  compovind  hypermetropic  astigmatism  all  the  meridians  of  the  eye 
are  hypermetropic  ;  but  one  of  them  more  so  than  any  of  the  others,  and 
the  meridian  at  right  angles  to  it  less  so  than  any  of  the  others.  In 
mixed  astigmatism  one  meridian  of  the  eye  is  myopic,  while  the  opposite 
meridian  is  hypermetropic.  In  irregular  astigmatism  different  parts  of 
the  same  meridian  possess  different  degrees  of  refraction.  Hence  this 
form  of  astigmatism  is  the  only  error  of  refraction,  which  can  not  be  cor- 
rected by  glasses.     It  is,  in  every  sense  of  the  word,  irremediable. 

It  is  obvious  that  persons  with  emmetropic  eyes,  and  with  unim- 
paired accommodation  and  well-balanced  ocular  muscles,  do  not  need 
spectacles.  Persons  with  any  of  the  different  forms  of  ametropia  are 
liable  to  become  the  subjects  of  asthenopia  from  eye-strain.  Such  per- 
sons complain  of  inability  to  use  their  eyes,  pain  in  their  eyes  and  tem- 
ples, headache,  nausea,  and  various  nervous  disorders. 

Hypermetropia  is  congenital,  as  a  rule,  and  is  said  to  be  due  to  an 
arrest  of  development  of  the  globe  in  its  an tero- posterior  axis.  It  is 
sometimes  the  result  of  changes  in  the  refractive  media,  as  in  the  harden- 
ing of  the  crystalline  lens  that  occurs  in  old  age,  or  the  removal  of  the 
lens  by  operations  for  cataract. 

Parallel  rays  of  light  passing  through  the  hypermetropic  pupil  do 
not  meet  on  the  retina,  but  converge  toward  a  point  behind  it.  Objects 
are,  therefore,  seen  under  circles  of  diffusion ;  and  such  eyes,  in  order 
to  see  distinctly,  contract  their  ciliary  muscles  sufficiently  to  so  increase 
the  convexity  of  the  crystalline  lens  that  the  focus  will  be  brought  for- 
ward upon  the  retina.  This  act  is  involuntary,  and  produces  more  or 
less  strain  upon  the  eyes.  For  such  jiersons  the  strongest  convex  spher- 
ical glasses  should  be  selected  with  which  they  can  distinctly  see  objects 
distant  twenty  feet  or  more.  If  the  asthenopic  symptoms  only  accom- 
pany or  follow  the  use  of  the  eyes  for  reading  and  other  near  work,  it 
may  be  sufficient  to  wear  the  glasses  only  for  the  near.  But  when  the 
asthenopic  symptoms  are  constant,  and  are  only  aggravated  by  near 
work,  the  glasses  should  be  worn  constantly. 

In  selecting  glasses  for  the  relief  of  asthenopia,  no  matter  what  the 
error  of  refraction,  it  is  always  well  to  examine  the  eyes  with  the  pupil 
dilated.  While  sulphate  of  atropia  is  the  most  reliable  mydriatic,  if 
used  in  solution  sufficiently  strong  to  paralyze  the  accommodation,  it 
incapacitates  the  eyes  for  near  vision  for  at  least  ten  days. 

When  the  object  is  to  ascertain  the  true  refraction  with  as  little  in- 
convenience to  the  patient  as  possible,  it  is  sufficient  for  all  practical 
purposes  to  drop  into  the  eyes  a  few  minims  of  a  3-per-cent  solution 
of  homatropine  hydrobromate  at  intervals  of  fifteen  minutes,  until  seven , 
or  eight  instillations  have  been  made,  and  to  test  the  refraction  ten  or 
fifteen  minutes  after  the  last  instillation.  If  the  homatropine  produces 
redness  of  the  eyes,  as  is  often  the  case,  this  may  be  relieved  by  a  single 
instillation  of  a  4-per-cent  solution  of  cocaine  hydrochlorate,  which,  at 
the  same  time,  increases  the  effect  of  the  homatropine  in  paralyzing  the 


REFRACTION.— THE   OPHTHALMOSCOPE.  429 

ciliary  muscle.  The  effect  of  these  mydriatics  passes  off  inside  of  twenty- 
four  hours.  In  cases  where  it  is  desirable  that  the  patient  should  have 
the  benefit  of  a  prolonged  rest  of  his  accommodation,  regardless  of  in- 
convenience, it  is  better  to  use  the  sulphate  of  atropia  (a  1-per-cent 
solution). 

In  some  cases  of  asthenopia  from  hypermetropia,  glasses  correcting 
the  total  error  of  refraction  are  woi-n  with  comfort  from  the  start.  In 
the  majority  of  cases,  however,  w^hen  the  accommodation  reasserts  itself, 
such  glasses  make  the  eyes  practically  myopic,  and  the  indistinctness 
of  vision  thus  produced  so  annoys  the  patient  that  he  rejects  them.  It 
is  safer,  therefore,  to  wait  until  the  hypermetrope  has  recovered  from  the 
effects  of  the  mydriatic,  and  then  to  order  the  strongest  convex  glasses 
that  he  can  wear  with  comfort.  When  his  eyes  have  become  accustomed 
to  these,  they  should  be  exchanged  for  stronger  ones,  and  these  changes 
should  be  repeated  at  intervals  of  two  or  three  months  until  the  total 
hypenneti'opia  is  corrected.  After  that  it  is  probable  that  the  patient 
will  need  no  further  change  of  glasses,  and  that  the  relief  of  his  asthe- 
nopia will  be  permanent. 

Myopia  may  be  apparent  or  real.  Apparent  myopia  is  due  to  spasm 
of  the  ciliary  muscle,  and  may  be  diagnosticated  from  true  myopia  by 
ascertaining  the  true  refraction  under  the  effects  of  atropine.  Spasm  of 
the  ciliary  muscle  is  usually  the  result  of  over-use  of  the  eyes.  Such 
patients  should  be  kejDt  under  atropine  for  several  weeks,  wearing  me- 
dium smoked  coquille  glasses  to  protect  the  retina  from  excessive  light. 
"When  the  spasm  of  the  ciliary  muscle  fails  to  reassert  itself  after  the 
use  of  the  mydriatic  is  stopped,  convex  glasses,  correcting  the  hyperme- 
tropia, which  almost  always  exists  in  such  cases,  should  be  substituted 
for  the  coquilles,  and  the  patiert  should  be  cautioned  not  to  resume 
the  excessive  near  use  of  his  eyes.  True  myopia  is  the  result  of  the 
lengthening  of  the  antero-posterior  diameter  of  the  eyeball,  and  is  rare- 
ly congenital.  There  often  exists  a  hereditary  tendency  to  myopia ;  and 
it  is  a  matter  of  common  observation,  that  where  the  father  or  mother 
is  myopic  the  children  are  apt  to  develop  the  same  condition  during 
school-life.  Myopia  is  frequently  developed  in  childi-en,  however,  where 
there  is  no  traceable  hereditary  tendency.  It  almost  invariably  first 
shows  itself  during  early  school-life,  and  the  first  intimation  of  it  is  that 
the  child  fails  to  see  the  letters  and  figures  on  the  blackboard  across  the 
school-room.  It  is  encouraged  by  the  use  of  the  eyes  by  insuilcient  light 
in  a  vitiated  atmosphere,  and  in  a  stooping  position,  during  the  period 
when  the  eyes  are  undergoing  rapid  development  along  with  the  other 
organs  of  the  body.  It  is  of  the  greatest  importance  that  it  should  be 
arrested  as  soon  as  possible  ;  for  highly  myopic  eyes  are  nearly  always 
diseased  eyes,  and  are  in  great  danger  of  developing  staphyloma  posti- 
cum,  retinal  and  choroidal  changes,  floating  bodies  in  the  vitreous,  and 
detachment  of  the  retina.  Myopic  patients  should  be  fitted  with  glasses 
at  as  early  a  period  as  possible,  the  weakest  concave  glasses  being 
selected  for  them,  with  which  they  can  see  distant  objects  distinctly. 
They  should  wear  such  glasses  constantly ;   by  so  doing,  arrest  of  de- 


430 


A  TEXT-BOOK   ON  SURGERY. 


velopment  of  the  ciliary  muscle  will  be  avoided,  as  will  also  excessive 
strain  upon  the  interni.  Attention  to  their  general  health  should  not 
be  neglected,  and  the  amount  of  use  of  their  eyes  for  near  work  should 
be  limited.  Their  eyes  should  be  tested  at  least  once  in  six  months, 
and  a  careful  record  kept  of  the  results  of  such  testings,  for  it  is  only 
in  this  way  that  we  can  tell  whether  the  myopia  is  stationary  or  pro- 
gressive, and,  if  the  latter,  whether  rapidly  so  or  not.  If  the  myopia 
is  increasing  rapidly,  near  work  should  be  entirely  stopped,  and  the 
patient  should  be  put  upon  atropine  and  colored  glasses,  and  turned  out 
into  the  open  air.  Myopia  usually  ceases  to  be  progressive  somewhere 
between  the  ages  of  twenty  and  thirty.  Aside  from  all  consideration  of 
the  health  of  the  eyes,  myopes  should  wear  the  correcting  glasses  for 
educational  reasons. 


liiitfkJLJ 


Fig.  428.— Nachet's  trial-set. 


Astigmatism,  especially  when  only  slight  and  correctable  by  an  un- 
equal contraction  of  the  ciliary  muscle,  is  a  prolific  source  of  asthenopia. 
When  it  exists  in  the  higher  degrees,  the  patient  makes  no  attempt  to 
correct  it ;  sees  indistinctly  at  all  distances,  and  is  comparatively  free 
from  asthenopic  symptoms.  The  slighter  degrees,  then,  should  be  cor- 
rected with  glasses  for  the  relief  of  asthenopia  ;  the  higher  degrees  for 
the  purpose  of  procuring  distinct  vision.  Of  course,  in  fitting  patients 
with  glasses  for  the  correction  of  astigmatism,  convex  and  concave  cylin- 
drical lenses  are  necessary.  For  simple  hypermetropic  astigmatism  that 
convex  cylindrical  glass  should  be  selected  which  brings  the  focus  of 


TESTING  FOR  GLASSES.  43I 

the  hypermetropic  meridian  forward  upon  the  retina,  and  thus  makes 
distinct  vision  possible  without  an  effort  of  accommodation.  For  sim- 
ple myopic  astigmatism  the  concave  cylindrical  glass  should  be  selected 
which  throws  the  focus  of  the  myopic  meridian  back  upon  the  retina, 
and  thus  renders  the  eye  practically  emmetropic.  For  compound  hyper- 
metropic astigmatism  a  convex  spherical  with  a  convex  cylindrical  glass 
is  necessary  ;  while  in  compound  myopic  astigmatism  the  error  of  refrac- 
tion is  corrected  by  the  combination  of  a  concave  spherical  and  a  con- 
cave cylindrical  glass.  Mixed  astigmatism  is  corrected  by  a  convex 
cylindric  and  a  concave  cylindric  combined,  and  with  their  axes  at  right 
angles  to  one  another. 

In  prescribing  glasses  for  astigmatism  the  greatest  care  should  be 
taken  to  adjust  the  axes  properly.  The  cylindric  trial-glasses  should 
always  be  placed  before  the  eyes  in  trial-frames  made  for  the  purpose, 
and  the  direction  of  the  axes  read  in  degrees  from  the  frames.  Ophthal- 
mologists use  Snellen's  test-types  in  examining  for  errors  of  refraction, 
and  the  cases  of  trial  glasses  made  by  Nachet  (Fig.  428)  are  as  good 
as  any. 

TESTisra  foe  Glasses. 

For  determining,  errors  of  refraction  and  fitting  patients  with  spec- 
tacles, the  surgeon  should  provide  himself  with  Snellen's  and  Jaeger's 
test-types  and  with  a  case  of  trial-glasses,  including  spherical  and  cylin- 
drical glasses,  convex  and  concave,  trial-frames  with  the  degrees  of  a 
semicircle  marked  upon  them,  etc.  The  patient  should  be  placed  at  a 
distance  of  twenty  feet  from  Snellen's  test-type,  with  the  light  shining 
upon  the  test-type  and  not  upon  the  face  of  the  patient.  Each  eye  should 
be  tested  separately,  the  other  being  kept  open  and  covered  with  a  screen, 

Snellen's  test-type  is  so  constructed  that  the  letters  in  each  line  sub- 
tend an  angle  of  five  minutes  at  the  distance  marked  in  feet  above  the 
line.  The  line  marked  loO  should  therefore  be  read  at  one  hundred  feet ; 
that  marked  20,  at  twenty  feet,  etc.  Vision  is  recorded  fractionally, 
the  distance  from  the  test-type  being  set  down  as  the  numerator,  while 
the  number  of  the  line  read  is  set  down  as  the  denominator.  Thus,  if 
a  person  with  his  right  eye  reads  Snellen  No.  70  at  twenty  feet,  the 
vision  would  be  recorded  thus  :  R.  V.  =  f|-.  If  with  his  left  eye  he  reads 
Snellen  No.  20  at  twenty  feet,  it  is  recorded  L.  V.  =  %%.  The  vision  of  the 
right  eye  would  be  two  sevenths  of  the  normal,  while  that  of  the  left  eye 
would  be  one,  or  normal.  If  a  j)atient  reads  %%  with  each  eye,  we  know 
that  his  vision  is  perfect  in  both  eyes,  but  still  he  may  be  liypermetropic, 
and  straining  his  accommodation  in  order  to  see  distinctly.  We  should 
always  test  such  a  patient  with  convex  spherical  glasses.  If  the  weakest 
glass  blurs  his  vision,  he  has  no  manifest  hypermetropia.  The  vision 
and  refraction  of  such  a  patient  shoukl  be  recorded  thus : 

R.  V.  =  f^  ;  E.     L.  V.  =  f^ ;  E.  (emmetropic). 

If  the  patient  can  read  Snellen  No.  20  at  twenty  feet  through  a  convex 
spherical  glass,  the  strongest  one  through  which  he  can  read  it  represents 
his  manifest  hypermetropia.     Thus — 


432  A  TEXT-BOOK   ON  SURGERY. 

R.  V.  =  H  ;  Hm.  1-75  D.  L.  V.  =  fa  ;  Hm.  1-50  D. 
would  mean  that  the  patient  had  perfect  vision  without  a  glass,  or  with 
any  convex  spherical  glass  from  the  weakest  up  to  +  1''''5  D-,  right  eye, 
and  +  1'50  D.,  left  eye  ;  but  that  stronger  glasses  than  those  indicated 
would  blur  his  vision.  Those  glasses  should,  therefore,  be  prescribed. 
If  the  patient  sees  less  than  |§,  we  may  suspect  myopia  or  astigmatism. 
For  instance,  the  formula — 

R-  V.  =  /A ;  M  with  -  4  D.     L.  V.  =  ^\ ;  ff  with  -3D. 
means  that,  without  glasses,  the  patient  sees  -^t^-^  with  his  right  eye,  and 
tA  with  his  left  eye,  and  that  —  4  dioptries  is  the  weakest  concave  glass 
with  which  he  can  read  |^  with  his  right  eye,  and  —  3  dioptries  the 
weakest  with  which  he  can  read  f-g-  with  his  left  eye.* 

Again,  the  patient  may  be  astigmatic.     Suppose  we  find — 
t  R.  V.  =  H ;  f^  with  +^1-25  D.  c.  ax.  90°. 
L.  V.  =  18- ;  M  with  +  1  D.  s.  C  +  1'50  D.  c  ax.  90°. 
We  have  here  sim]Dle  hypermetropic  astigmatism  in  the  right  eye,  and 
compound  hypermetropic  astigmatism  in  the  left.     In  the  right  eye,  the 
vision  is  brought  up  to  f  g^  by  a  convex  cylindric,  one  and  a  quarter  diop- 
tries, axis  90° ;  while  in  the  left  the  combination  of  a  convex  spherical 
and  a  convex  cylindrical  is  required. 
In  another  case^- 

R.  V.  =  ^Vo- ;  I"-  with  -  3-25  D.  c.  ax.  180°. 
L.  V.  =  ^f  0  ;  IS-  with  -  3-75  D.  s.  C  -  2  D.  c.  ax.  180°. 
Here  we  have  simple  myopic  astigmatism  in  the  right,  and  compound 
myopic  astigmatism  in  the  left.     In  mixed  astigmatism  the  refraction 
may  be  corrected  and  the  vision  brought  up  to  the  normal  by  either  of 
three  different  combinations  of  lenses.     Thus — 

R.  V.  =  1^  ;  f^  with  +  1  D.  c.  ax.  90°  C  -  1  D.  c.  ax.  180°. 
L.  V.  =  f  t ;  fi  with  +  2  D.  c.  ax.  90°  C  -  2  D.  c.  ax.  180°. 
The  equivalent  glasses  would  be — 

R.  +  1  D.  s.  C  -  2  D.  c.  ax.  180°. 
L.  +  2  D.  s.  C  -  4  D.  c.  ax.  180°.     Or, 
R.  -  1  D.  s.  C  +  2  D.  c.  ax.  90°. 
L.  -  2  D.  s.  C  +  4  D.  c.  ax.  90°. 
In  fitting  patients  with  cylindric  glasses  the  direction  of  the  axes  is 
read  from  the  degrees  marked  on  the  trial-frames  toward  which  the  axes 
point  in  giving  the  best  vision. 

Presbyopia^  or  old  sight,  is  an  impairment  of  the  accommodation 
due  to  the  gradual  hardening  of  the  crystalline  lens,  the  result  of  age. 
Persons  who  are  emmetropic,  or  slightly  hypermetropic,  usually  need 
glasses  for  near  purposes  when  from  forty  to  forty -five  years  of  age. 
The  higher  degrees  of  hypermetropia  necessitate  the  use  of  glasses  for 
reading  much  earlier.     In  the  lower  degrees  of  myopia  the  use  of  glasses 

*  In  the  dioptric  scale  of  numbering  spectacle-lenses  the  unit  is  a  weak  lens  of  100  centi- 
metres focal  length,  or  D.  (one  dioptre).     A  lens  with  focal  length  of  50  cm.  =  (2  D.),  etc. 

t  This  reads:  Right  vision  equal  '^%\  \%  with  convex  1'25  Dioptries,  cylindric,  axis  90°. 
Left  vision  equal  1^ ;  f  J^  with  (-1-)  convex  1  D.  spherical,  (G)  combined  with  convex  1'50 
D.  cylindric,  axis  90°. 


TESTING  FOR   GLASSES.  433 

for  reading  may  be,  deferred  considerably  longer,  -n-liile  in  tlie  higher 
degrees  they  may  never  be  needed  at  all.  Presbyopes,  no  matter  what 
their  refraction,  should  be  suited  with  the  glasses,  generally  convex, 
with  which  we  find  experimentally  they  can  read  most  comfortably. 
Generally  the  weaker  convex  glasses  are  selected  in  the  early  stages  of 
presbyopia,  and  these  are  exchanged  for  stronger  ones  as  the  patient 
advances  in  life. 

Heterophoria. — Insufficiency  of  the  extrinsic  ocular  muscles — latent 
or  dynamic  squint. 

When  the  extrinsic  ocular  muscles  are  not  well  balanced,  as  when  the 
interni  are  relatively  stronger  than  the  externi,  or  one  of  the  inferior 
recti  weaker  than  its  fellow  of  the  opposite  side,  there  is  a  tendency  of 
one  eye  to  deviate  in  the  direction  of  the  relatively  stronger  muscle.  If 
the  eye  should  actually  deviate,  diplopia  (double  vision)  would  result, 
and  would  be  productive  of  great  annoyance.  Therefore,  single,  binocu- 
lar vision  is  always  maintained  as  long  as  possible,  and  in  order  to  its 
maintenance,  an  extra  innervation  has  to  be  supplied  to  the  weaker  mus- 
cle. This  constant  strain  causes  asthenopia,  headache,  nervousness,  etc. 
In  some  cases  the  strain  can  be  removed  by  the  iise  of  prisms  worn 
with  their  bases  toward  the  weaker  muscles,  alone,  or  combined  with 
the  lenses  which  coixect  any  existing  eiTor  of  refraction.  But  in  many 
cases  it  becomes  necessary  to  restore  equilibrium  of  the  muscles  by  a 
tenotomy  of  the  stronger  or  a  tendon  resection  of  the  weaker  muscle. 

The  different  kinds  of  correctable  heterophoria  (tendency  to  deviation 
of  the  visual  lines)  are :  1.  Hyperphoria  (a  tendency  upward  of  one  eye). 
2.  Exophoria  (a  tendency  outward).     3.  Esophoria  (a  tendency  inward). 

In  order  to  ascertain  vdxh  accuracy  the  kind  and  amount  of  hetero- 
phoria, the  surgeon  should  provide  himself  with  a  phororaeter  (an  in- 
strument of  precision  invented  by  Dr.  George  T.  Stevens,  of  N'ew  York), 
and  a  set  of  square  prisms,  of  one  degree  and  upward. 

The  patient  is  seated  facing  a  lighted  candle,  which  is  situated  on  a 
level  with  his  eyes,  and  twenty  feet,  or  more,  distant.  The  horizontal 
bar  of  the  phorometer  is  placed  in  front  of  his  eyes  and  a  few  inches 
away  from  them.  In  a  slot  in  this  horizontal  bar  is  placed  a  frame  con- 
taining two  prisms  of  4°  to  8°  each,  bases  toward  the  nose,  and  on  look- 
ing at  the  candle  through  these  prisms,  the  images  are  thrown  to  the 
nasal  side  of  the  macula,  and  the  patient  has  homonymous  dijilopia. 
If  both  inferior  recti  are  of  equal  strength,  and  likewise  both  superior 
recti,  neither  eye  will  deviate  upward,  and  the  two  candles  will  appear 
in  a  horizontal  line,  or  on  a  level.  But  if  one  eye  deviates  upward,  the 
image  will  be  thrown  upon  the  supero-nasal  quadrant  of  the  retina  of 
that  eye,  and  will  be  seen  on  a  lower  level  than  that  seen  with  the  other 
eye.  The  prism  placed  before  the  eye  that  sees  the  lower  candle,  base 
down,  which  brings  the  candles  on  a  level,  measures  the  amount  of 
hyperphoria. 

Having  tested  for  hyperphoria,  the  horizontal  prisms  should  be  re- 
moved and  replaced  by  a  prism  base  down  in  front  of  one  eye.  This 
wiU  produce  vertical  diplopia  by  throwing  the  image  of  the  candle-flame 


434  A  TEXT-BOOK   ON  SURGERY, 

on  the  retina  below  the  macnla,  so  that  it  will  be  projected  above.  If 
the  two  flames  are  seen  in  a  vertical  line,  there  is  no  insufficiency  of 
the  interni  or  externi.  But  if  the  images  are  homonymous,  there  is 
insufficiency  of  the  externi ;  and  the  prism,  base  out,  that  makes  them 
vertical,  measures  the  esophoria. 

If  the  images  are  crossed,  there  is  insufficiency  of  the  interni ;  and 
the  prism,  base  in,  that  makes  them  vertical,  measures  the  exophoria. 
In  making  these  tests,  the  horizontal  bar  of  the  phorometer  must  be 
carefully  adjusted  by  means  of  the  attached  screw  or  ratchet  and  spirit- 
level. 

In  order  to  arrive  at  a  more  positive  idea  as  to  the  relative  strength 
of  the  ocular  muscles,  it  is  necessary  to  measure  (1)  the  abduction,  (2) 
the  adduction,  and  (3)  the  sursumduction. 

The  abduction  is  measured  by  the  strongest  prism  that  can  be  over- 
come by  the  externi — that  is,  the  strongest  prism,  base  in,  through  which 
the  patient  can  see  singly  at  twenty  feet  or  more.  In  like  manner, 
the  strongest  prisms,  base  out,  through  which  the  patient  has  binocular 
single  vision,  measure  the  adduction  ;  and  the  strongest  prism,  base 
down,  over  one  eye,  through  which  the  patient  sees  singly,  measures  the 
sursumduction. 

In  hyperphoria  of  1°  or  more,  the  superior  rectus  of  the  hyperphoric 
eye  may  be  divided ;  in  esophoria  of  2°  or  more,  the  internus  may  be 
cut ;  and  in  exophoria  of  2°  or  more,  the  externus  may  be  snipped.  But 
if  the  surgeon  would  avoid  an  over-correction,  thus  leaving  the  eyes  in 
a  worse  condition  than  before,  he  must  follow  the  method  advocated  by 
Stevens : 

1.  Make  a  small  opening  in  the  conjunctiva  over  the  tendon  to  be  cut. 

2.  Seize  the  center  of  the  tendon  with  delicate  but  strong  forceps, 
made  for  the  purpose,  and  button-hole  it  with  delicate  probe-pointed 
scissors. 

3.  Introduce  one  blade  of  the  same  scissors  between  the  tendon  and  the 
sclera  and  the  other  blade  between  the  tendon  and  the  conjunctiva,  and 
cut  transversely  to  one  border  of  the  tendon,  and  then,  reversing  the 
scissors,  cut  transversely  to  the  other  border  of  the  tendon. 

4.  The  eyes  should  now  be  tested  with  prisms,  and  if  the  heterophoria 
is  not  nearly  corrected,  the  scissors  may  be  again  inti-oduced  and  the  loos- 
ening up  of  the  insertion  be  carried  a  little  further.  Thus  by  cutting 
cautiously,  a  little  at  a  time,  and  then  testing  with  candle  and  prisms  to 
ascertain  how  much  eifect  has  been  obtained,  it  is  not  difficult  for  the 
dexterous  operator  to  correct  the  deviation  with  considerable  accuracy. 
No  surgeon  should  undertake  these  operations  with  the  ordinary  clumsy 
instruments  in  vogue.  The  necessary  instruments  particularly  adapted 
to  the  purpose,  and  to  tendon-resection,  are  made  by  Messrs.  Tiemann 
&  Co.,  of  New  York.  Tendon-resection  is  practiced  in  cases  whei'e  the 
heterophoria  is  too  great  to  be  corrected  by  a  graduated  tenotomy  of  the 
stronger  muscle  without  limiting  the  excui-sion  of  the  eye  in  that  direc- 
tion. In  such  cases  it  is  better  to  partly  correct  the  deviation  by  tenot- 
omy and  to  correct  what  remains  by  tendon-resection  of  the  weaker  mus- 


OPHTHALMOSCOPY. 


435 


cle.  In  performing  this  operation,  by  Stevens's  method,  the  tendon  is 
divided  as  in  graduated  tenotomy.  A  delicate  hook  is  then  slipped  be- 
neath and  caught  into  the  under  surface  of  the  divided  tendon  which 
is  now  drawn  out  of  the  conjunctival  aperture  and  caught  some  lines 
from  its  extremity  with  delicate  fixation  forceps.  A  small,  very  sharp, 
curved  needle,  armed  with  a  fine  silk  thread,  is  now  passed  through  the 
muscle  from  without  inward,  as  far  back  as  the  operator  thinks  neces- 
sary, and  then  the  portion  of  the  muscle  anterior  to  the  needle  is  excised 
with  scissors.  The  needle  is  then  carried  through  the  stump  of  the  in- 
sertion of  the  muscle,  including  the  capsule  of  Tenon  and  overlying 
conjunctiva,  and  the  thread  drawTi  through  and  loosely  tied. 

The  patient  should  now  be  placed  in  the  position  for  testing  with 
prisms,  and  the  knot  drawn  just  tight  enough  to  correct,  or  slightly  over- 
correct,  the  deviation.  In  both  these  operations  the  lids  may  be  held 
open  by  a  speculum,  an  elevator,  or  the  fingers  of  an  assistant.  The 
stitch  may  be  removed  at  the  end  of  three  or  four  days.  No  after-treat- 
ment is  required,  as  there  is  rarely  any  inflammatory  reaction. 


Ophthalmoscopy. 

The  general  practitioner  should  familiarize  himself  with  the  xise  of  the 
ophthalmoscope  sufficiently  to  be  able  to  diagnosticate  gross  lesions  of 
the  globe  situated  posterior  to  the  crystalline  lens.  He  should  provide 
himself  with  an  ophthalmoscope  with  tilt- 
ing mirror  and  convex  and  concave  lenses 
ranging  from  one  to  twenty  dioptries.  With 
this  it  would  not  be  amiss  for  him  to  ex- 
amine the  eyes  of  all  his  patients,  so  far  as 
his  time  would  allow.  He  should  dilate  the 
pupils  with  a  solution  of  homatropine  or 
cocaine,  two  per  cent  in  either  case,  in  order 
to  facilitate  the  examination.  The  patient 
should  be  seated  in  a  darkened  room,  with 
a  German  student's  lamp  placed  on  a  level 
with  the  eye  to  be  examined,  a  little  behind 
and  to  one  side,  so  that  the  light  will  fall 
on  the  temple  or  nose  but  not  on  the  eye. 
The  observer  then  rests  the  ophthalmoscope 
against  the  inner  angle  of  his  orbit  and 
throws  the  light  into  the  eye  with  the  mir- 
ror, at  the  same  time  looking  into  the  pupil 
through  the  aperture  in  the  mirror.  He 
thus  gazes  at  the  papillary  area  while  the 
patient  looks  up,  down,  right,  and  left.  If 
the  reflex  from  the  pupil  is,  in  all  positions 
of  the  eye,  of  a  uniform  clear  pinkish  or  reddish  color,  it  is  to  be 
inferred  that  there  are  no  gross  lesions  of  the  refractive  media.  If  the 
red  reflex  from  the  fundus  is  interrupted  by  dai'k  spots,  there  are  opaci- 


FiG.  429. 
Student's  Ophthalmoscope. 


436  A  TEXT-BOOK   ON  SURGERY. 

ties  of  the  media,  and  the  surgeon  must  proceed  to  locate  them.  If  they 
move  while  the  eye  is  fixed,  they  are  floating  bodies  in  the  vitreous. 
If  they  move  with  the  eye  and  stop  when  the  eye  stops,  they  are  opaci- 
ties either  of  the  cornea  or  of  the  crystalline  lens.  If  of  the  cornea,  they 
will  be  seen  by  oblique  illumination.  This  is  also  true  of  opacities  situ- 
ated on  the  anterior  capsule  and  in  the  front  portions  of  the  crystalline 
lens.  If  in  the  posterior  portions  of  the  lens,  they  will  appear  to  move  in 
an  opposite  direction  to  the  eye.  Opacities  in  the  periphery  of  the  lens 
are  seen  only  when  the  eye  is  so  turned  that  the  observer  looks  through 
the  pupil  very  obliquely.  For  more  minute  examination  of  any  opacity 
already  discovered,  the  observer  should  turn  on  over  the  aperture  of  his 
ophthalmoscope  a  -\-  10.  D.,  and  approach  the  eye  to  within  its  focal  dis- 
tance, about  four  inches.  In  this  way  he  will  obtain  a  greatly  magnified 
view.  In  high  degrees  of  myopia  and  hypermetropia  pigment  patches 
in  the  fundus  may  be  mistaken  by  the  novice  for  opacities  of  the  media. 
These  are  excluded  by  seeing  them  in  their  true  position  while  examin- 
ing the  fundus. 

There  are  two  methods  of  examining  the  fundus  :  1,  The  indirect ;  2, 
the  direct. 

In  examining  the  eye  by  the  indirect  method,  the  observer  interposes 
a  two-inch  or  two-and-a-half-inch  lens,  between  his  ophthalmoscope  and 
the  patient's  eye,  at  about  its  focal  distance  from  the  eye,  his  own  eye 
being  twelve  to  fifteen  inches  away.  In  this  manner  he  gets  an  inverted 
image  of  the  fundus,  magnified  some  three  or  four  diameters.  By  direct- 
ing the  patient  to  look  successively  in  different  directions,  he  thus  easily 
scans  the  whole  fundus. 

In  using  the  direct  method,  the  observer  approaches  his  eye  with  the 
ophthalmoscope  as  close  as  possible  to  the  eye  he  is  examining,  often 
touching  the  brow  or  nose  of  the  patient  with  his  instrument.  In  this 
way  he  sees  only  a  small  portion  of  the  fundus  at  a  time,  but  that  is  in 
its  true  position  and  is  magnified  some  seventeen  diameters,  more  or  less. 
The  examined  eye  being  myopic,  he  must  turn  on  the  toeakest  concave 
lens  with  which  he  can  see  the  fundus  distinctly  ;  and  this,  while  it  en- 
ables him 'to  see  the  fundus  clearly,  at  the  same  time  measures  the 
amount  of  myopia.  If  the  patient  is  hypermetropic  in  a  moderate  de- 
gree, the  fundus  will  be  well  seen  without  any  lens  ;  but  if  the  observer 
would  estimate  the  amount  of  hypermetropia,  he  must  turn  on  the  strong- 
est convex  lens  through  which  he  can  see  the  fundus  distinctly.  In 
astigmatism  only  one  meridian  of  the  fundus  is  seen  distinctly  at  a  time, 
the  opposite  meridian  being  seen  through  a  stronger  or  weaker  lens.  If 
the  observer  has  an  error  of  refraction,  he  must  take  it  into  account  in 
estimating  refraction  with  the  ophthalmoscope.  Some  of  the  grosser 
lesions  to  be  looked  for  by  the  surgeon  are : 

1.  Optic  Neuritis. — Here  the  ojihthalmoscopic  appearances  vary.  In 
the  milder  cases  only  the  nasal,  or  upper,  or  lower,  border  of  the  disk  is 
obscured  by  swelling,  while  in  the  severer  cases  the  whole  papilla  is 
greatly  swollen  and  its  outline  entirely  obliterated.  The  retinal  vessels 
are  tortuous,  while  the  veins  are  enlarged  and  the  arteries  are  either  of 


OPHTHALMOSCOPY. 


437 


normal  size  or  diminished.  There  may  or  not  be  ecchymoses  upon  the 
disk  or  in  the  retina.  Rarely  the  central  vision  and  visual  field  are  per- 
fect. In  most  cases,  however,  both  are  impaired,  and  often  vision  is  re- 
duced to  perception  of  light.  In  optic  neuritis  or  "choked  disk"  of 
both  eyes  intracranial  tumors  should  always  be  suspected.  Optic  neu- 
ritis may,  however,  depend  on  a  variety  of  causes,  such  as  kidney  dis- 
ease, lead-poisoning,  meningitis,  syphilis,  etc. 

2.  AtropJiy  of  tJie  Optic  Nerve  is  recognized  by  the  paleness  of  the 
optic  disk  and  the  smallness  of  the  retinal  blood-vessels.  It  may  be  con- 
secutive to  optic  neuritis,  or  it  may  be  ushered  in  as  "primary"  atrophy. 
Therefore  the  conditions  which  produce  optic  neuritis  should  be  sought 
in  cases  of  atrophy.  It  frequently  occurs  in  poisoning  by  tobacco  and 
alcohol,  and  is  often  a  symptom  of  progressive  locomotor  ataxia.  It  is 
found  in  advanced  stages  of  retinitis  pigmentosa. 

3.  Retinitis  is  distinguished  by  bright  or  whitish  patches  in  the 
retina.  AVhen  these  arrange  themselves  about  the  macula  lutea  in  a  stel- 
late form,  the  cause  is  generally  found  to  be  kidney  disease.  They  are 
often  accompanied  by  retinal  haemorrhages.  Diabetes  and  syphilis  are 
among  the  other  causes  of  retinitis. 

4.  Choroiditis  is  known  by  white  patches  in  the  fundus,  generally 
bordered  irregularly  with  black  pisment,  and  with  the  retinal  vessels 
passing  over  them.  The  cause  is  often  obscured.  It  is  sometimes  due 
to  syphilis. 

5.  Glaucoma  simplex  is  always  characterized  by  excavation,  or 
cupping  of  the  optic  disk.  The  retinal  vessels  appear  to  end  abrupt- 
ly at  the  discal  border.  The  bottom  of  the  excavation  can  be  seen 
through  a  sufiiciently  strong  concave  lens.  Around  the  disk  is  a  ring 
of  choroidal  atrophy  exposing  the  white  sclera.  There  is  often  pulsa- 
tion of  the  retinal  arteries.  Central  vision  is  usually  impaired,  and 
the  visual  field  limited,  especially  on  the  nasal  side. 


Fio.  429  A. — Ophthalmoscopic  appearance  of 
healthy  fundus  in  a  person  of  very  fair 
complexion.  Scleral  ring  well  marked. 
Lett  eye,  inverted  image.  (Wccker  and 
Jaeger.) 


Fig.  429  b.— Ophthalmoscopic  appearance  of 
severe  recent  papillitis.  Several  elongated 
patches  of  blood  near  border  of  the  cen- 
tral inflammatory  area.  (Alter  Hughlinga 
Jackson  and  Nettlesliip.) 


438 


A  TEXT-BOOK   ON   SURGERY. 


Surgery  of  the  Eak. 

Neoplasms  of  tlie  auricle  require  extirpation  as  in  other  portions  of 
the  body.  Angeiomata  of  small  size  may  be  cured,  without  excision,  by 
injecting  the  tumor  with  a  few  minims  of  50-per-cent  carbolic-acid  solu- 
tion. Cartilaginous  growths  are  occasionally  met  with  about  the  ear. 
Their  usual  location  is  just  in  front  of  the  tragus.  I  removed  two  in 
front  of  one  ear  and  one  from  the  opposite  side  in  a  patient  twenty-two 
years  of  age.  Similar  tumors  were  present  in  the  person  of  his  father 
and  another  member  of  the  family. 

Wounds  of  the  auricle  should  be  treated  with  the  view  of  preventing 
any  distortion  of  this  organ. 

Lacerations  of  the  lobule  from  the  violent  removal  of  an  ear-ring  may 
be  corrected  by  jDaring  the  edges  and  uniting  them  by  fine  silk  sutures. 
The  hypodermic  use  of  cocaine  will  secure  perfect  aneesthesia  in  all  or- 
dinary operations  upon  the  auricle. 

Drooping  of  the  ears  to  a  degree  amounting  to  deformity  should  be 
treated  in  children  by  strapping  the  auricles  close  to  the  skull,  by  means 
of  an  elastic  band  around  the  forehead  and  occiput. 


Fig.  430.— (After  Eoeves.; 


■piG.  431.— (After  Reeves.) 


Adhesions  of  the  auricles  to  the  scalp  should  be  dissected  loose,  the 
organs  crowded  forward,  and,  if  necessary,  skin  should  be  transplanted 
to  fill  in  the  gap  and  prevent  a  recurrence  of  the  deformity.  Hyper- 
trophy of  the  auricle  should  be  corrected  by  excision  of  a  triangular 
piece,  after  the  method  of  Martino,  shown  in  Figs.  480  and  431. 


Fig.  432. — Sexton's  hard-rubber  double  probe. 


Auditory  Canal. — Foreign  bodies  in  the  auditory  canal  may  be  recog- 
nized by  inspection  or  with  the  light  gutta-percha  probe  (Fig.  432),  and 
should  be  removed  by  the  careful  employment  of  the  angular  forceps 


SURGERY   OF  THE  EAR. 


439 


(Fig.  433),  or,  if  firmly  impacted,  the  ring  curette  (Fig.  434)  may  be  re- 
quired. For  locating  and  seizing  the  body  the  head-mirror  should  be 
employed  to  concentrate  the  light  in  the  canal.  '  The  solid-silver  specu- 


FiG.  434. — Sexton's  double  ear-hook,  to  extract  foreign    bodies. 

lum  of  WDde,  always  required  in  examinations  of  the  deeper  portions  of 
the  canal  and  of  the  membrana  tympani,  may  also  be  of  assistance  in 
locating  the  foreign  body,  although  this  can  usually  be  done,  if  the  light 
is  properly  directed,  by  pulling  upon  the  auricle  so  as  to  straighten  the 
canal. 

Impactions  of  cerumen  should  be  removed  by  irrigation  with  warm 
water.  The  stream  should  be  delicate,  and  should  be  directed  to  one 
side  of  the  obstraction  in  order  to  melt  away  a  portion  sufficient  to  allow 
the  force  of  the  injection  to  operate  upon  the  mass  from  behind.  The 
curette  or  scoop  may  also  be  advantageously  employed  in  removing  im- 
pactions of  cerumen. 

Fwrundes  of  the  auditory  canal  are  quite  frequently  met  with.  Their 
presence  is  marked  by  acute  pain,  located  in  a  circumscribed  area,  and 
by  redness  and  swelling. 

The  treatment  consists  in  alleviating  pain  by  the  use  of  anodynes  if 
necessary,  and  by  softening  the  skin  over  the  inflammatory  process  by 
the  use  of  emollients.  Cotton  lubricated  with  vaseline  should  be  intro- 
duced. As  soon  as  the  formation  of  pus  is  evident,  it  should  be  evacuated 
by  puncture  or  incision. 


Fig.  435. — Sexton's  snare. 


Neoplasms  of  the  auditory  canal  demand  removal  by  the  snare  (Fig. 
435),  forceps,  or  by  excision.     Polypus  of  this  tube  may  be  single  or 


440  A  TEXT-BOOK   ON    SURGERY. 

multiple,  and,  when  of  sufficient  size  to  fill  the  canal  and  become  con- 
stricted, may  break  down  and  cause  a  foetid  discharge. 

Occasionally  the  auditory  canal  is  occupied  by  a  parasite  known  as 
aspergillus,  the  spores  of  which  are  developed  with  great  rapidity,  fill- 
ing up  the  canal  and  causing  inflammation,  obstruction,  and  more  or  less 
interference  with  hearing.  Finely  powdered  boracic  acid  should  be 
blown  deeply  into  the  canal  at  repeated  intervals  until  the  fungus  is 
destroyed. 

Middle  Bar — Memhrana  Tympani. — The  drum  of  the  ear  may  be- 
come involved  by  extension  of  an  inflammation  from  the  auditory  canal, 
or  it  may  be  secondary  to  an  otitis  media,  or  it  may  in  rare  instances  be 
inflamed  without  either  of  the  foregoing  complications. 

Inflammation  of  the  middle  ear  is  in  most  cases  preceded  by  pharyn- 
gitis, and  is  thus  affected  by  invasion  through  the  Eustachian  tube.  It 
may  be  produced  by  traumatism,  or  the  initial  lesion  may  be  situated 
within  the  cavity  of  the  tympanum,  or  in  the  mastoid  cells,  which  com- 
municate with  the  cavity.  Otitis  media  is  not  uncommon  in  children  as 
a  sequel  of  scarlatina  or  rubeola. 

The  earliest  symj^tom  of  this  affection  is  pain  of  a  severe  character, 
accompanied  by  partial  arrest  of  hearing.  Fever  is  present,  and  may 
be  preceded  by  a  chill  or  rigors.  When  suppuration  occurs,  and  the 
mastoid  cells  are  involved,  the  pain  is  intensified  and  the  febrile  move- 
ment at  times  very  high.  In  a  case  of  this  character  which  I  saw,  and 
in  which  the  operation  of  puncture  and  trephining  the  mastoid  process 
had  been  delayed,  fatal  pyaemia  occurred.  In  specimens  of  blood  taken 
from  this  patient  just  before  death,  the  red  blood-disks  were  seen  to  be 
filled  with  bacteria.  Percussion  with  the  finger-tip  over  the  mastoid 
region  exaggerates  the  sense  of  pain.  Upon  examination  with  the  oto- 
scope and  head-light,  the  drum  of  the  ear  wUl  be  seen  to  be  more  opaque 
than  normal,  its  vascularity  increased  and  bulging  toward  the  meatus  if 
there  is  pus  in  the  middle  ear. 

The  treatment  of  otitis  media  shoxild  be  directed  to  the  arrest  of  the 
inflammatory  process  by  warm  fomentations,  by  the  application  of 
leeches  to  the  temples  and  mastoid  region.  Quinia,  iron,  stimulants, 
and  well-selected  diet  are  indicated  in  the  effort  to  improve  the  general 
condition  of  the  patient.  It  is  of  great  moment  that  the  tension  of  the 
tympanum  and  of  the  mastoid  cells  should  be  relieved  early  in  the 
progress  of  the  disease,  and,  even  when  there  is  a  doubt  as  to  the  pres- 
ence of  pus,  explorative  puncture  of  the  membrana  tympani  should  be 


Fio.  436. — Politzer's  tympanum-perforator,  angular. 

made.  The  operation  is  without  danger,  is  not  difficult  of  accomplish- 
ment, and,  even  when  suppuration  has  not  occurred,  will  often  give 
great  and  immediate  relief.     A  proper  instrument  for  this  procedure  is 


SFRGERY  OF  THE   EAR.  441 

shown  in  Fig.  436.  The  silver  speculum  and  reflected  light  shoiild  be 
employed  so  as  to  bring  the  membrane  into  plain  view,  and,  while  the 
head  of  the  patient  is  held  motionless,  the  point  of  the  perforator  is 
carried  against  the  drum  on  its  posterior  inferior  quadrant,  and  barely 
pushed  through.  The  puncture  should  not  be  more  than  one  eighth  of 
an  inch  in  length.  If  there  shall  have  been  an  eifusion  of  serum,  or  if 
pus  is  present  upon  the  withdrawal  of  the  instrument,  a  small  quantity 
of  fluid  will  escape  through  the  puncture.  If  necessary  to  the  estab- 
lishment of  free  drainage,  the  opening  may  be  enlarged. 

When  otitis  media  is  complicated  with  inflammation  and  suppuration 
of  the  mastoid  cells,  and  when  the  communication  with  the  tympanum 
is  not  sufficient  to  give  ready  discharge  to  the  products  of  inflammation 
into  the  middle  ear,  and  thence  out  through  the  puncture  in  the  7nem- 
hrana  tympani,  the  cells  should  be  opened  and  drainage  secured  at  once 
by  removing  the  outer  shell  of  the  mastoid  j)rocess.  In  children  this  pro- 
cedure is  not  always  necessary  on  account  of  the  very  thin  shell  of  bone 
which  incloses  the  cavity  of  the  mastoid  antrum,  and  which  readily 
gives  way  and  allows  egress  to  the  pus  formed  within.  In  drilling  or 
trephining  the  mastoid  cells,  proceed  as  follows  : 

The  skin  over  and  near  the  mastoid  process  should  be  shaved  and 
cleansed,  and  a  free  incision  made  in  a  vertical  dii-ection,  the  center  of 
the  cut  being  opposite  the  center  of  the  auditory  meatus  and  one  fourth 
of  an  inch  from  the  posterior  wall  of  the  bony  canal.  If  any  difficulty 
is  experienced  in  lifting  and  reflecting  the  integument,  a  short  trans- 
verse cut  should  be  made  backward  from  the  middle  of  the  perpendicu- 
lar incision.  The  periosteum  should  be  scratched  off  at  the  point  where 
the  bone  is  to  be  perforated,  unless  necrosis  has  already  occurred  and 
only  a  thin  shell  of  bone  remains.  In  this  condition  the  shell  should 
be  lifted  off  and  the  cells  cleaned  out.  AVhen  the  bone  has  a  healthy 
appearance  on  the  exterior  it  should  be  cut  through  with  a  trephine, 
gouge,  chisel,  or  diUl.  The  trephine  employed  should  not  be  more  than 
a  quarter  of  an  inch  in  diameter,  and  the  center  of  the  hole  made  (no 
matter  what  instrument  is  employed)  should  not  be  farther  than  a  quar- 
ter of  an  inch  posterior  to  the  wall  of  the  auditory  canal  on  account  of 
the  proximity  of  the  lateral  sinus  and  the  veins  of  the  diploe  which 
empty  into  it.  After  the  instrument  has  traveled  about  an  eighth  of 
an  inch  into  the  bone  it  should  be  removed  and  the  circular  track  in- 
spected. The  entrance  to  the  cells  will  be  indicated  by  a  slight  haemor- 
rhage, and,  if  abscess  is  present,  by  a  few  drops  of  pus.  As  soon  as 
the  bleeding  is  seen  the  button  of  bone  should  be  lifted  by  the  elevator 
and  the  remaining  cancellous  tissue  scooped  out  with  the  iron  spoon  or 
the  scalloped  gouge.  The  abscess  should  be  irrigated  with  a  l-to-3000 
sublimate  solution,  and  the  wound  dressed  with  a  loose  sublimate  gauze 
dressing.  If  the  trephine  is  not  used,  the  scalloped  gouge  (Fig.  69),  the 
bone-drill  (Fig.  72),  the  scoop  (Fig.  68),  or  the  chisel  and  mallet  may  be 
substituted.  If  (as  has  occurred  in  several  instances)  marked  bleeding 
occurs — probably  from  wounding  some  large  vein  near  its  entrance  into 
the  sinus — it  may  be  arrested  by  packing  with  sublimate  gauze  and 


442  A  TEXT-BOOK  ON  SURGERY. 

tlie  drainage  establislied  a  few  hours  later,  when  the  hjemorrhage  has 
ceased,  by  substituting  a  loose  dressing. 


The  Nose. 

Acquired  Lesions. — Fracture  of  the  bones  of  the  nose  has  been 
already  considered. 

Epistaxis,  or  hsemorrhage  from  the  nose,  is  often  severe  enough  to 
demand  surgical  interference.  The  bleeding  may  at  times  be  arrested 
by  diminishing  the  blood-pressure  in  the  vessels  of  the  nose  by  ligation 
of  the  extremities.  This  consists  in  applying  an  elastic  bandage  (or  an 
ordinary  roller,  if  the  rubber  can  not  be  obtained)  around  the  thighs  and 
arms  close  to  the  trunk,  and  making  the  j^ressure  strong  enough  to  arrest, 
in  great  part,  the  return  of  blood  through  the  veins  without  arresting  the 
circulation  in  the  arteries.  When  the  hsemorrhage  ceases  the  ligatures 
should  be  gi-adually  loosened,  so  that  the  volume  of  blood  which  has 
been  confined  in  the  extremities  may  not  be  too  suddenly  returned  to 
the  heart.  Plugging  or  tamponing  the  nares,  if  properly  done,  will 
succeed  if  all  other  methods  fail.  First,  determine  accurately  the  nostril 
in  which  the  bleeding  is  occurring.  Take  a  piece  of  fine  sponge  at  least 
an  inch  in  diameter  when  dry  (and  it  should  be  introduced  without  being 
moistened,  so  that  when  in  position  in  the  posterior  nares  it  will  expand 
as  the  blood  moistens  it),  and  tie  around  its  center  three  strong  silk 
threads.  A  soft  catheter  or  bougie  is  now  introduced  into  the  nostril 
from  the  front,  keeping  the  point  of  the  instrument  well  on  the  floor  of 
the  nose.  As  soon  as  the  end  is  seen  or  felt  behind  the  saft  palate,  it  is 
drawn  out  at  the  mouth  by  the  forceps  or  fingers.  Two  of  the  three 
threads  are  attached  to  the  point  of  the  instrument,  which  is  then  pulled 
back  through  the  nostril.  When  the  threads  come  out  of  the  nose  in 
front  they  are  seized  by  the  fingers  of  one  hand  wliile  the  sponge  is  care- 
fully guided  into  position  behind  the  soft  palate  with  the  other.  Once 
well  in  the  posterior  naris  it  is  held  in  position  and  made  to  exert  the 
necessary  compression  by  tying  the  two  anterior  strings  over  a  softened 
sponge  packed  into  the  nostril  in  front.  The  third  thread  is  brought  out  of 
the  mouth,  and  is  to  be  used  in  dislodging  the  tampon  when  the  hsemor- 
rhage has  ceased.  Lint,  soft  rags,  or  cotton  may  be  used  for  plugs  when  a 
sponge  can  not  be  obtained.  A  long  probe  or  a  loop  of  soft  wire  may  be 
used  instead  of  the  bougie.  The  application  of  a  4-to-8  per  cent  solution 
of  cocaine  hydrochlorate  to  the  mucous  membrane  of  the  nose  may  prove 
useful  as  a  hgemostatic,  since  Bosworth  has  demonstrated  that  it  causes 
marked  diminution  in  the  caliber  of  the  vessels  of  the  lining  membrane. 

Foreign  Bodies. — Buttons,  seeds,  and  other  substances  are  often 
lodged  in  the  cavity  of  the  nose.  The  usual  seat  of  lodgment  is  in  the 
anterior  part  of  the  inferior  meatus,  or  between  the  lower  turbinated 
bone  and  the  septum,  and  occasionally  they  are  pushed  beyond  this  into 
the  middle  meatus.  When  allowed  to  remain,  inflammation  of  the  lining 
membrane  always  ensues,  and  ostitis  is  not  infrequent. 


THE  NOSE.  443 

The  diagnosis  depends  upon  physical  exploration  by  means  of  the 
head-mirror,  a  strong  light,  and  the  metal  probe.  The  presence  of  a 
body  lodged  in  the  nasal  cavity  may  be  at  times  indicated  by  the  change 
of  the  voice  from  its  natural  to  a  nasal  tone.  Removal  is  urgent,  and 
may  be  effected  by  inspiration  through  the  mouth  and  forced  expiration 
through  the  nose,  with  the  mouth  and  nostril  of  the  unaffected  side 
closed.  In  adults  the  act  of  sneezing  will  sometimes  succeed  in  dislodg- 
ing the  substance.  A  strong,  slender  forceps,  bent  at  an  angle  so  that 
the  hand  of  the  operator  will  not  shut  out  the  light,  is  the  most  suit- 
able instrument  to  be  employed  in  its  removal.  When  the  body  is 
lodged  well  back  it  may  be  pushed  through  into  the  pharynx  and  eject- 
ed from  there. 

Rhinolites,  or  nasal  calculi,  are  occasionally  foiand  in  these  cavities. 
It  is  probable  that  they  come  from  the  lachrymal  apparatus,  since  they 
are  found  in  the  immediate  neighborhood  of  the  entrance  of  the  nasal 
dact.  Moreover,  dacTiryolites,  or  lachrymal  concretions,  are  not  very 
infrequent  in  the  lachrymo-nasal  apparatus.  These  bodies  should  be 
removed  with  the  forceps  as  soon  as  discovered. 

Neoplasms. — The  most  frequent  variety  of  tumor  vdthin  the  nasal 
cavity  is  the  myxoma,  or  so-called  gelatinous  polypus.  Next  in  order 
of  frequency  is  the  fibroma,  or  fibrous  polypus.  Both  of  these  belong 
microscopically  to  the  connective-tissue  tumors,  the  myxomata  being 
allied  to  the  embryonic,  the  fibromata  to  the  more  developed  connective- 
tissue  tumors.  Papillomata,  or  warts,  are  not  infrequently  seen  at  the 
edges  of  the  mucous  membrane  of  the  nostrils.  Lastly,  there  may  be  a 
general  hypertrophy  of  the  mucous  membrane  of  the  nose,  causing  a 
tumefaction  of  the  turbinated  tufts,  and  partial,  or  may  be  complete, 
occlusion  of  the  nares. 

Gelatinous  nasal  polypi  are  usually  pear-shaped,  the  bulk  of  the 
tumor  tending  toward  the  floor  of  the  nose.  The  jjedicle  is  attached  to 
one  of  the  thick  velvety  tufts,  most  frequently  in  the  upper  or  middle 
meatus.  There  may  be  a  single  tumor,  although  the  rule  is  for  them 
to  be  multiple.  They  are  of  light  grayish  color,  and  are  covered  by  a 
mucous  exudation. 

The  symptoms  are  chieiiy  those  due  to  pressure  and  obstruction  of  the 
nares.  Changes  in  the  voice  are  not  marked  until  the  presence  of  the 
tumor  has  been  suspected  from  pressure  and  irritation.  This  initation 
gives  rise  to  an  excessive  secretion  and  discharge  from  the  nose,  and 
occasionally  to  j)rolonged  and  violent  fits  of  sneezing. 

The  diagnosis  may  be  rendered  positive  by  physical  exploration. 
The  shrinkage  of  the  turbinated  tufts,  following  the  local  use  of  cocaine 
hydrochlorate,  renders  inspection  more  easy. 

Treatment. — The  only  rational  method  of  treatment  is  removal  and 
destruction  of  the  pedicle  and  contiguous  mucous  membrane.  Avulsion 
may  be  effected  by  seizing  the  growth  with  a  long,  delicate  polypus-for- 
ceps, and  twisting  the  tumor  around  until  the  pedicle  is  wrung  off,  then 
applying  pure  nitric  acid  or  the  galvano-caiitery  to  the  stump.  The 
wire  ecraseur  or  snare  of  Jarvis  is  greatly  to  be  preferred  (Fig.  437). 


444 


A  TEXT-BOOK   ON   SURGERY. 


After  the  wire-loop  has  been  passed  around  the  tumor,  and  slipped  np 
to  the  pedicle,  it  should  be  slowly  tightened,  since  by  this  method  the 
danger  of  haemorrhage  which  always  follows  the  use  of  the  forceps  is 
avoided.     From  one  to  two  hours  may  be  consumed  in  the 
division  of  the  growth,  the  screw  being  turned  from  time  to 
time.     Nitric  acid  or  the  cautery  should  be  applied  to  the 
stump  in  all  cases,   since  without  this  recurrence  is  almost 
certain. 

Fibromata,  or  fibrous  polypi,  are  much  less  frequent  than 
the  myxomata.  As  a  rule  they  are  deeper  situated.  They  re- 
quire the  same  treatment  as  above  given.  Occasionally  large 
tumors  of  the  nasal  cavities  require  for  their  complete  removal 
section  of  the  nasal  and  superior  maxillary  bones.  In  this 
procedure  the  skin  and  periosteum  should  be  left  intact,  and 
osteoplasty  performed  in  order  to  prevent  necrosis. 

Papillomata,  or  warts,  which  occur  at  the  junction  of  the 
mucous  membrane  of  the  nares  with  the  integument,  should 
be  clipped  off  with  curved  scissors  and  their  bases  burned  with 
pure  nitric  acid. 

HypertropTiy  of  the  turbinated  tufts  may  exist  to  such  an 
extent  as  to  demand  interference.  Such  enlargement  should 
be  treated  exactly  as  one  would  treat  true  polypus. 

Fissures  of  the  nares  may  be  relieved  by  the  repeated  local 
use  of  the  lunar-caustic  pencil. 

Ozcena. — Ozgena  is. the  name  given  to  a  chronic  inflamma- 
tion of  one  or  more  of  the  nasal  cavities,  or  the  sinuses  com- 
municating with  them.  It  may  be  confined  to  a  process  of 
ulceration  of  the  soft  tissues  alone,  but  not  infrequently  there 
is  an  ostitis.  Syphilitic  ozsena  is  probably  the  most  common 
form.  It  frequently  occurs  with  other  dyscrasise.  It  is  accom- 
panied by  a  fetid  odor  and  a  muco-purulent  discharge,  par- 
tially liquid  and  partially  solid.  Atrophy,  or  destruction  of 
the  turbinated  tufts,  is  not  infrequent,  so  that  there  is  abnor- 
mal space  within  the  nares. 

The  treatment  is  local  and  general.  The  removal  of  dis- 
eased or  dead  bone  is  imperative,  and  irrigation  with  the 
weaker  sublimate  or  boracic-acid  solutions  should  be  regularly 
made. 

Dobbell's  solution  will  be  found  of  use :    Carbolic  acid, 
gr.  x;  biborate  and  bicarbonate  of  soda,  each,  3j;  glycerin, 
3  x ;  to  this  add  water  to  make  §  x.     This  should  be  used  five 
or  six  times  a  day  a  s  a  douche.     The  general  condition  of  the     fio.  437.— 
patient  should  be  improved   by  the  administration  of  well-        snarl^ 
selected  tonics  and  food,  and  by  out-of-door  life. 

Superficial  epithelioma,  situated  upon  the  nose  or  face,  should  be 
destroyed  by  the  application  of  Marsden's  paste.  It  is  made  of  arsenious 
acid  and  powdered  gum  acacia,  equal  parts,  with  enough  water  to  make 
a  fairly  soft  paste.    It  may  be  left  on  from  twelve  to  twenty -four  hours — 


THE   NOSE. 


445 


as  long  as  the  patient  can  end^^re  the  pain.  Poultices  are  applied  after- 
ward. If  the  first  application  is  not  sufficient,  it  should  be  repeated. 
The  loss  of  substance  caused  by  the  destructive  action  of  the  paste  may 
be  repaired  by  a  plastic  operation  ;  but  this  should  not  be  done  until 
cicatrization  has  occurred. 

The  frontal  sinus  may  be  involved  in  some  of  the  diseases  which 
affect  the  nose.  New  growths,  abscess,  or  ostitis  may  demand  the  appli- 
cation of  the  trephine  in  the  removal  of  a  neoplasm  or  dead  bone,  or  the 
evacuation  of  pus. 

Deviation  of  the  nose  from  the  median  line  may  be  congenital  or 
acquired.  The  septum  alone  may  project  to  one  side,  or  the  entire  organ 
be  disijlaced  laterally  or  ttpward.  When  the  distortion  is  due  to  malfor- 
mation of  the  bones,  these  must  be  forced  into  position,  with  or  without 
fracture. 

Deviation  of  the  septum  to  such  an  extent  that  deformity  is  pro- 
duced or  one  nostril  closed  often  requires  correction. 

The  method  of  Prof.  John  B.  Roberts  has  yielded  good  results. 

Make  a  long  incision  at  the  most  prominent  portion  of  the  deviation, 
and  supi^lement  this  by  chopping  the  septum  fall  of  incisions  with  the 
stellate  punch.  If  there  is  an  angular  deviation  close  to  the  palatal 
process  of  the  superior  maxillary  bone,  make  an  incision  from  front 
to  back  at  the  most  prominent  part,  and  do  not  chop  the  upper  por- 
tion with  the  stellate  punch.     If  the  deviation  is  a  curved  one,  split  the 

cartilage  along  the  most  promi- 
nent portion  and  then  chop  the 

Fig.  isrA.-Eoberts's  nasal  pin.  ~'  TeSt    of    the    Septum    Until    it    haS 

lost  its  resiliency.  Aftem-ard 
cut  away  with  the  chisel  or  saw  any  horizontal  bony  edge  that  may 
remain  at  the  bottom.  If  some  small  trian- 
gular pieces  are  removed  by  the  interlacing 
of  the  incisions  made  \A-ith  the  forceps,  it 
makes  no  difference,  since  the  openings  left 
are  very  small  and  will  soon  become  closed. 
To  hold  the  septum  in  place,  use  steel  pins 
(Fig.  437  a),  either  those  with  spherical 
heads  of  glass,  or  the  flat-headed  pins  which 
were  devised  some  years  ago.  When  the 
head  of  the  pin  is  to  be  within  the  nostril, 
those  with  the  glass  heads  are  better  ;  when 
the  head  is  to  lie  against  the  exterior  of  the 
nose,  the  flat  heads  are  preferable. 

After  having  divided  the  septum  («,  Fig. 
437  b),  as  above  described,  introdttce  a  pin 
(5)  into  the  more  open  nostril  and  thrust 
its  point  through  the  anterior  part  of  that 
portion  of  the  divided  septtim.    Displace  this 

part  into  the  desired  position,  thrust  the  point  of  the  pin  onward  and 
bury  its  point  deep  in  the  tissues  at  the  back  part  of  the  nasal  chamber 


Fig.  437b. — Roberts's  method  of  hold- 
ing the  septum  in  correct  position 
by  means  of  pins.  The  upper  part 
of  the  septum,  immediately  above 
the  oblique  incision,  projected  too 
far  this  way  (i.  e.,  toward  the  read- 
er). It  is  now  pressed  the  other 
way  (i.  e.,  from  the  reader),  and 
is  held  there  by  tlie  pins,  a,  In- 
cision throush  the  septum.  6,  c, 
Pins  in  position. 


446  A  TEXT-BOOK   ON  SURGERY. 

which  was  formerlj^  occluded.  This  holds  the  septum  firmly  in  its  new 
location.  The  head  of  this  pin  will  be  just  inside  of  the  anterior  naris 
which  was  not  obstructed,  and  will  lie  against  the  columella.  It  should 
be  allowed  to  remain  about  one  week,  for  if  left  a  longer  time  its  head 
will  probably  cause  ulceration  of  the  columella,  and  may  become 
deeply  buried  in  the  tissues  of  the  columella.  Its  work  is  usually 
accomplished  within  a  week.  It  is  often  well  to  introduce  a  second  pin 
(c.  Fig.  437  b),  from  the  external  surface  of  the  front  of  the  nose  just 
below  the  nasal  bones,  which  aids  in  keeping  the  septal  cartilage  pinned 
into  proper  place.  If  this  pin  has  a  flat  head,  it  may  be  covered  with  a 
small  square  of  court-plaster.  The  patient  can  then  go  about  the  streets 
without  attracting  attention. 

In  many  instances  hypertrophy  of  the  turbinated  bones,  or  permanent 
thickening  of  the  vascular  membrane  covering  them,  obstructs  the  nose 
to  such  an  extent  that  the  passage  of  air  by  these  channels  is  difficult  or 
impossible,  or  deviation  of  the  septum  may  result.  Under  such  con- 
ditions, removal  of  the  turbinated  bones  and  tufts  is  indicated.  The 
inferior  tuft  is  commonly  implicated.  A  sufficient  degree  of  ansesthesia 
may  usually  be  obtained  by  the  cai^eful  apjilication  of  cocaine  hydro- 
chlorate — 4-per-cent  solution — brought  directly  in  contact  with  the  mu- 
cous surfaces  to  be.  iucised  by  means  of  pellets  of  cotton,  attached  to 
delicate  probangs.  A  small  quantity  may  be  employed  through  the 
nostril  by  means  of  the  atomizer.  When  the  ansesthesia  is  effected,  the 
turbinated  bone  may  be  sawed  through  at  its  attachment  to  the  superior 
maxilla.  Should  hsemoj-rhage  be  troublesome,  it  may  be  arrested  by 
plugging  the  nostril. 

Hypertrophy  of  the  nose,  due  to  increased  vascularity,  may  be  cor- 
rected by  repeated  incisions  across  the  track  of  the  enlarged  vessels,  by 
galvano-puncture,  or  by  causing  their  obliteration  by  injections  of  50-per- 
cent carbolic-acid  solution,  as  for  ncevus. 

Plastic  Surgery  op  the  JSTose. 

Loss  of  substance  may  occur  from  the  accidental  or  surgical  ablation 
of  all  or  a  portion  of  this  organ,  or  from  its  destruction  by  disease.  The 
diseases  which  most  frequently  produce  loss  of  substance  are  sypMUs 
and  lupus.  Carcinoma,  sarcoma,  elephantiasis,  or  any  neoplasm,  may 
involve  the  nose  and  cause  loss  of  tissue  in  their  removal,  but  lupus 
locates  itself  by  preference  here,  while  one  of  the  most  common  lesions 
of  tertiary  syphilis  is  necrosis  of  the  cartilages  and  bones  of  the  nose, 
resulting  in  great  disfigurement.  Occasionally  sloughing  occurs,  from 
the  presence  of  a  phagedenic  syphilide  during  the  second  stage  of  this 
disease.  This  accident  occurred  in  the  patient  from  which  Fig.  447 
was  taken. 

Rliinoplasty  may  be  partial  or  complete.  Complete  rhinoplasty  is 
performed  when  the  skin,  cartilages,  and  bone  of  the  nose  have  been 
carried  away.  In  such  cases  nothing  remains  but  an  irregular  sunken 
pit,  leading  almost  directly  into  the  pharynx. 


PLASTIC   SURGERY  OF  THE  NOSE. 


447 


The  successful  and  satisfactory  restoration  of  tMs  organ  is  not  often 
acMeved.  It  would  be  well,  in  all  cases  of  complete  loss  of  the  nose, 
to  try  some  form  of  prothetic  apparatus  before  resorting  to  a  plastic 
operation. 

The  operation  consists  (1)  in  paring  the  margins  of  the  opening  and 
the  integument  immediately  around  the  opening,  in  apposition  to  which 
the  transplanted  flap  is  to  be  brought ;  (2)  in  the  transportation  of  a 
properly  shaped  piece  of  skin,  with  its  underljdng  tissues,  from  its  nor- 
mal to  the  new  position. 

The  flap  may  be  taken  entirely  from  the  forehead,  or  one  half  from 
each  cheek,  or  from  the  arm.  One  of  the  most  frequent  causes  of  failure 
in  this  operation  is  the  caving  in  of  the  ridge  of  the  new  nose,  and,  in 
order  to  better  support  this  part,  the  end  of  one  of  the  fingers  may  be 
utilized,  as  follows : 

First  Metliod — Complete  Rhinoplasty  from  theForeJiead  and  Finger. 
— Remove  the  nail  and  matrix  of  one  finger  of  the  left  hand,  split  and 
dissect  up  the  integument  on  the  palmar  surface  of  this  finger,  as  far  back 
as  the  last  interphalangeal  articulation,  and  sew  this  to  the  already 
freshened  edges  of  the  nasal  opening.  The  arm,  hand,  and  head  should 
now  be  immovably  fixed  in  a  jjlaster-of-Paris  dressing,  in  which  position 
it  remains  for  about  four  Aveeks.  When  the  circulation  is  freely  estab- 
lished between  the  vessels  of  the  face  and  the  transplanted  finger,  the 
latter  should  be  amputated  at  the  first  or  second  interphalangeal  articu- 
lations, as  may  be  necessary  to  have  it  of  suflicient  length  to  support 
the  covering  of  integument.  After  several  weeks'  delay,  to  assure  the 
permanent  vitality  of  the  transplant- 
ed phalanx,  a  flap  may  be  turned 
from  the  forehead  to  the  nose,  as 
follows  : 

Cut  a  piece  of  chamois-skin,  or 
soft,  thin  leather,  of  the  shape  rep- 
resented in  Fig.  438.  Adjust  this 
to  the  line  of  the  nasal  cavity,  to  see 
if  it  is  large  enough  and  of  projoer 
shape.  Bear  in  mind  the  following- 
points  :  1.  The  flap  once  dissected  up 
tends  to  contract.  It  should  there- 
fore be  slightly  larger  than  a  pattern 
which  fits  exactly.  2.  The  isthmus 
id,  Fig.  438)  miist  not  be  too  nan-ow, 
for  fear  that  the  vitality  of  the  flap 
may  be  insufficient.  It  should  al- 
ways be  cut  so  as  to  include  the  an- 
gular artery.  3.  The  distance  from 
the  isthmus  {d)  to  (e  e),  where  the 
lower  edge  of  the  new  nose  is  to  be,  should  be  considerably  less  than  the 
distance  from  d  to  a  c,  in  order  to  prevent  tension  of  the  flap  and  inter- 
ference with  the  circulation  through  the  pedicle,  d.     Lay  the  pattern  on 


Fig.  438.— (After  Linl}art.) 


448 


A  TEXT-BOOK   ON  SURGERY. 


the  forehead  and  outline  the  flap  by  making  punctures  at  intervals  of 
every  fourth  of  an  inch  along  its  edges.  The  incision,  made  through  all 
the  tissues  down  to  the  periosteum,  should  begin  at  d  and  be  carried  to 
a  c  c  a,  and  then  down  to  a  point  near  the  eyebrow,  at  d,  in  the  line  of 
the  freshened  margin  of  the  nasal  cavity.  The  smaller  incisions  in  the 
flap  ab  ov  cb  are  made  to  provide  for  the  septum  and  alee  of  the  new 
nose.  If  the  finger  has  been  grafted  for  the  support  of  the  flap,  the  in- 
cisions of  Labat,  cb,  cb,  will  sufiice ;  if  not,  those  of  Lin  hart,  ab,  ab, 
will  give  a  doubly  folded  septum,  and  one  less  likely  to  fall  or  cave  in. 
The  flap  is  now  dissected  up  from  the  periosteum  as  far  as  the  pedicle, 
when  it  is  turned  down  and  sewed  into  position  with  fine  silk  sutures. 
The  secondary  flap  for  the  septum  is  first  doubled  on  itself,  and  then 
bent  in  at  a  right  angle  to  the  axis  of  the  nose,  and  stitched  down,  as 
shown  in  Fig.  439,  to  the  center  of 
the  lowest  portion  of  the  nose,  just 
above  the  middle  of  the  upper  lip, 
while  the  alee  are  also  folded  in  and 
sewed,  as  represented  in  the  same 
cut.     The  operation    is   completed 


Fig.  440. — (After  Malgaigne.) 


J  —  {  Vtar  Liuhart.) 

■when  the  entire  flap  has  been  ac- 
curately stitched  to  the  freshened 
edges  of  the  cavity,  as  shown  in 
Fig.  440.  Pieces  of  rubber  tubing 
may  be  inserted  in  the  nostrils  to 
hold  the  alee  in  position.    The  upper 

part  of  the  wound  on  the  forehead  is  drawn  as  near  together  as  can  be 
done,  with  silk  or  silver- wire  sutures,  and  a  sublimate  or  iodoform  gauze 
dressing  is  applied.  No  pressure  must  be  exercised  upon  the  pedicle,  or 
flap,  which  should  be  loosely  enveloped  in  the  dressing.  In  about  two 
weeks  the  circulation  will  have  been  sufficiently  established  between  the 
flap  and  the  edges  of  the  cavity  to  permit  the  section  of  the  pedicle,  the 
stump  of  which  is  used  in  filling  up  the  gap  upon  the  forehead.  In  re- 
turning the  pedicle  to  its  original  position,  it  is  advisable  to  scrape  out 
the  granulation-tissue  in  the  bottom  of  the  wound,  so  that  the  returned 
portion  will  sink  to  the  proper  level. 

Among  other  methods  of  performing  complete  rhinoplasty  is  that 
of  Dieifenbach,  as  shown  in  Fig.  441,  or  that  of  Koenig,  Fig.  442,  in 
which  the  pedicle  is  somewhat  wider  than  in  the  other  flaps.  The  flap 
of  Langenbeck  is  shown  in  Fig.  443.  These  varioiis  operations  of  trans- 
planting the  flap  from  the  forehead  are  modifications  of  the  Hindoo 


PLASTIC  SURGERY  OF  THE  NOSE. 


449 


Fig.  441.— Dieffenbach's  method.     (After  Linhart.) 

miethod.  Fig.  444  represents  a  rhino- 
plasty done  by  a  Hindoo  surgeon  in 
1793. 

Second  Method — Complete  Rhino- 
plasty from  the  Arm. — Freshen  the 
mara-ins  of  the  nasal  cavitv  as  before. 


Fio.  442. — Koenig'a  method.     (After  Koenig.' 


Fig,  443. — Langenbeck?3  inoision.     (After  Koenig.) 


Flu.   141. — (After  Szymimowsky.) 


Transplant  a  portion  of  the  finger  as  before  described,  if  the  septnm  nasi 
has  completely  disappeared.  Place  the  palm  of  the  hand  on  the  top  of 
the  head,  Fig.  445,  so  that  the  anterior  surface  of  the  humeral  i-egion 
will  be  in  close  proximity  to  the  face.  Calculate  the  length  and  breadth 
of  the  flap  required  to  be  raised  from  the  arm,  and  outline  it  with  ink. 
Fit  a  strong  wire  cuirass  or  the  upper  half  of  Bauer's  wire  bi-eeches  com- 
fortably and  sectirely,  so  that  the  head  and  neck  may  be  held  immovable. 
Or  apply  a  plaster-of -Paris  jacket,  which  shall  cover  the  head.  Mold  a 
strip  of  one-quarter-inch-thick  gutta-percha  to  the  arm  and  forearm,  or, 
if  this  material  can  not  be  obtained,  sole  leather  or  shellac  may  be  sub- 

29 


450 


A  TEXT-BOOK   ON  SURGERY. 


stituted,  so  that  with  the  hand  on  the  occiput  and  the  inteiijarietal 
suture,  the  strip  may  be  fitted  to  the  antero-lateral  aspect  of  the  corset 
and  along  the  arm,  forearm,  and  hand,  as  in  Fig.  445.  Next  dissect  the 
integument  from  the  deltoid  region  down  toward  the  elbow,  making  it 

extra  long  and  wide,  and  lifting  every- 
thing down  to  the  deep  fascia.  When  the 
haemorrhage  has  ceased,  dress  the  wound 
in  the  arm  with  sublimate  gauze,  apply 
the  gutta-percha  mold,  fix  it  upon  the  cor- 
set with  a  tight  roller,  fasten  it  and  the 
underlying  hand  to  the  skull-piece  or 
helmet  (a  a,  Fig.  445)  and  accessory,  sup- 
porting strips  of  strong  adhesive  plaster, 
as  at  b.  Lastly,  stitch  the  edges  of  the 
flap  to  the  freshened  margins  of  the  nasal 
rim.  The  circulation  between  the  face 
and  skin  of  the  arm  should  be  sufficiently 
established  from  the  tenth  to  the  four- 
teenth day  to  permit  section  of  the  flap. 

Since  the  skin  of  the  arm  is  very  thin, 
and  after  transplantation  is  apt  to  shrink 
away,  it  is  a  wise  precaution  to  dissect 
up  the  flap  from  the  shoulder  and  arm, 
making  it  longer  than  may  at  first  ajDpear 
necessary — and  to  do  this  eight  or  ten  days  before  the  arm  is  fastened  in 
the  immovable  apparatus.  The  flap  in  this  way  shrinks,  and  is  covered 
with  granulations,  in  which  condition  iinion  with  the  integument  of  the 
face  is  accelerated  and  assured. 

When  the  vascular  connection 
is  safely  established,  the  pedicle  is 
cut,  the  arm  released,  and  the  flap 
shaped  and  stitched  in  position,  as 
in  the  preceding  operation.  ^SS^     "  'y^-- 


Fig.  445.— (After  Lm]iart.) 


Fig.  446. — (.After  Szymanowsky.) 


Wutzer  took  the  integument  from  the  forearm ;  Fabrizzi  from  near 
the  elbow  (Fig.  446). 


PLASTIC   SURGERY  OF  THE  NOSE. 


451 


Partial  Rhinoplasty . — 

When  there  is  only  a  par- 
tial loss   of   substance   the 

operation   is  less  difficnlt, 

and  the  prospect  of  success 

greater.     When  one  ala  is 

involved,  as  shown  in  one 

of  my  cases  (Fig.  447),  the 

flap  may  be  made  from  the 

cheek  (Fig.  448).     In  this 

patient  I  trimmed  the  cica- 
tricial edges  of  the  scar  and 

turned  a  flap,  as  indicated 

by  the   dotted    lines,    and 

stitched  it  to  the  nose.    The 

wound  in  the  face  was  par- 
tially   closed    by    sutures. 

The    pedicle    was    divided 

on  the  fourteenth  day  and 

turned  back  into  the  wound, 

the     gramilations     having 

been     previously     scraped 

out.     Or  the  flap  may  be  

borrowed  from  the  side  of 

the  cheek,  leaving  the  ped-  j,  ^^  ^g 

icle  above,  as  in  Fig.  450. 

When  the  tip  of  the  nose  is  eroded,  the  method  indicated  in  Fig.  451 

should  be  adopted.     The  broad  end  of  the  flap  is  split ;  the  center  strip 

(a)  is  for  the  septum,  while 
those  at  h  h  are  to  complete 
the  eroded  alee. 

I 


\  ^' 


Fig.  449. — Transplanted  portion  in  the  new  position  after 
division  and  return  of  the  pedicle. 


Fig.  450.— (.After  Lmhart.) 

When  in  the  removal  of 
small  neoplasms  the  ala  nasi 
is  perforated,  the  wound  may 


452 


A  TEXT-BOOK   ON  SURGERY. 


be  closed  by  sutures,  or  the  gap  may  be  filled  by  a  small  graft  of  skin 
lifted  entirely  from  the  arm  or  abdomen,  and  transplanted  upon  the  nose. 

Operations  of  minor  im- 
portance are  at  times  per- 
formed to  correct  lesser  de- 
formities. 


Fig.  452.— (After  Linhart.) 


Fig.  451.— (After  Linhart.) 


Fig.  453.— (After  Linhart.) 

When  the  alse  are  too  thick, 
elliptical  pieces  may  be  ex- 
cised and  the  edges  closed,  as 
in  Figs.  452  and  453.  If  the 
tip  of  the  nose  is  too  pointed 
and  upturned,  it  may  in  part 
be  corrected  by  exsecting  a  triangular  piece  from  the  septum  and  closing 
the  gap  with  sutures. 

Congenital  Lesions  of  the  Nose. — Occasionally  the  lateral  halves  of 
the  nose  fail  to  unite,  resulting  in  the  deformity  known  as  bifid  nose. 
There  may  be  partial  or  complete  absence  of  this  organ,  or  when  present 
the  nares  may  be  occhided,  or  it  may  be  complicated  with  the  extreme 
cases  of  hare-lip.  The  operative  procedure  for  the  relief  of  this  last 
deformity  will  be  given  in  connection  with  congenital  cleft  of  the  lip. 
Occlusion  of  the  nares  may  be  relieved  by  cutting  through  the  mem- 
brane in  the  direction  of  the  normal  opening.  For  the  correction  of 
forked-nose,  or  the  absence  of  this  organ,  no  fixed  rule  of  practice  can  be 
laid  down. 


The  Lips  and  Cheeks. 


Wounds. — Accidental  wounds  of  the  lips  are  usually  incised  or  lacer- 
ated. If  badly  torn,  the  ragged  edges  should  be  smoothly  trimmed, 
washed  with  sublimate  solution,  and  secured  with  interrupted  silk 
sutures.  When  the  wound  is  through  the  entire  thickness  of  the  lip, 
the  sutures  should  include  the  mixcous  membrane.  A  very  fine  suture 
or  pin  should  be  used  in  the  vermilion  border  to  insure  absolute  approxi- 


THE  LIPS  AND   CHEEKS.  453 

mation  here.  Adhesive  strips  are  not  reliable.  In  children  one  or  two 
pin-sutiires  shonld  be  preferred,  as  they  best  resist  the  constant  strain 
to  which  sutures  of  the  parts  are  subjected  in  the  act  of  crying. 

Diseases  of  the  Lips. — Among  the  diseases  which  involve  the  lips 
and  the  contiguous  structures  are  epithelioma^  lupus,  papillovia,  navus, 
cysts,  lipoma,  adenoma,  phlegmon,  ulcers,  and  general  hypertrophy 
and  fissures. 

Epithelioma. — One  of  the  most  frequent  causes  of  removal  of  portions 
of  the  lips  is  the  presence  of  epithelioma.  It  is  a  disease  of  middle  and 
old  age,  involves  usually  the  lower  lip,  and  occurs  in  the  great  majority 
of  instances  iu  males.  Epithelioma  may  attack  the  lip  without  any  ap- 
preciable cause,  but  in  most  cases  the  appearance  of  the  neoplasm  is 
preceded  by  prolonged  irritation  at  the  place  involved.  A  jagged  or 
projecting  tooth,  the  habitual  use  of  a  pipe-stem  or  cigar,  are  frequent 
causes  of  this  disease.  It  wOl  also  result  from  the  irritation  caused  by 
chronic  fissure  or  ulcer  of  the  lip. 

Symptoms. — It  begins  as  a  small  ulcer  with  rather  abrupt  margins,  in 
the  bottom  of  which  is  a  dirty  granulation-tissue  partially  hidden  by 
thin  pus.  In  its  earlier  stages  it  is  not  readily  distinguished  from  the 
benign  ulcer  w^hich  is  found  upon  the  lip.  The  preceding  history  of  a 
prolonged  irritation  should  always  suggest  epithelioma,  especially  if  it 
occurs  after  the  age  of  thirty,  and  upon  the  lower  lip.  Ulcer  is  apt  to 
occur  in  one  of  the  scrofulous  or  tubercular  diathesis.  If  grave  doubt 
exists  as  to  its  malignant  nature,  the  application  of  the  solid  stick  of 
nitrate  of  silver  should  be  made.  An  ordinary  ulcer  will  heal  rapidly 
under  this  stimulus,  while  the  epithelioma  is  not  affected.  Labial  chancre 
may  be  differentiated  by  the  indurated  base,  which  is  characteristic  of 
this  lesion.  Adenitis  in  the  line  of  lymphatics  along  the  lower  jaw  comes 
on  in  the  earlier  stages  of  syphilis,  while  in  epithelioma  the  sore  may 
exist  for  months  Avithout  perceptible  enlargement  of  the  lymphatic 
glands.  In  syiDhilis  the  appearance  of  the  eruption,  together  with  the 
history  of  the  case,  will  lead  to  correct  differentiation. 

Epithelioma  of  the  lip  is  a  dangerous  affection.  Left  alone,  it  de- 
stroys life  within  a  period  varying  from  one  to  four  years.  It  spreads  at 
times  vdth  rapidity,  eating  away  the  tissues  in  all  directions.  It  may 
confine  itself  to  the  soft  parts,  or  attack  the  maxillary  and  nasal  bones. 
Engorgement  of  the  submental,  sublingual,  submaxillary,  and  cervical 
glands  is  almost  inevitable  if  the  disease  is  not  extirpated  in  the  first  few 
months  of  its  history.  The  glandular  enlargement  is  at  first  not  always 
due  to  metastasis,  but  may  result  from  simple  adenitis  following  the  in- 
flammatory process  in  the  margins  of  the  ulcer. 

Treatment. — The  early  excision  of  the  diseased  tissue  is  imperative. 
The  knife  should  always  be  preferred  to  the  use  of  corrosive  substances. 
The  incision  should  be  wide  of  the  diseased  area — at  least  half  an  inch 
from  the  infiltrated  margin.  If  the  disease  has  existed  long  enough  to 
have  caused  lymphatic  enlargement,  the  infiltrated  glands  must  also  be 
extirpated. 

The  prognosis  as  to  a  permanent  cure  is  always  doubtful,  although 


454  A  TEXT-BOOK  ON  SURGERY. 

wlien  the  operation  is  performed  early  in  tlie  history  of  the  disease  a 
cure  may  be  effected.  In  many  cases  where  recurrence  after  operation 
is  jjrobable,  life  may  be  prolonged  and  rendered  more  endurable  by  ex- 
cision of  the  ulcer.  After  a  primary  excision  the  patient  should  be  kept 
under  close  observation,  and,  upon  the  reappearance  of  the  neoplasm  in 
the  scar  or  lymphatics,  a  second  operation  should  be  performed.  In 
1884  I  removed  a  large  number  of  infiltrated  glands  from  the  neck  of  a 
man  about  fifty  years  old,  who  had  had  an  ejpithelioma  of  the  lip  excised 
twelve  years  previous  to  that  date.  Five  years  after  the  first  operation  a 
gland  at  the  lower  edge  of  the  jaw  became  enlarged  and  was  extirpated. 
Six  years  later  the  glands  beneath  the  jaw  began  to  swell,  and  a  year 
later,  when  I  saw  him,  metastasis  had  seemingly  occurred  in  all  the 
lymphatics  as  far  down  as  the  lower  third  of  the  neck  on  one  side.  The 
infiltration  was  so  extensive  and  deep  that  it  took  two  operations,  each 
lasting  about  three  hours,  to  effect  the  removal.  The  examination  of 
the  glands  demonstrated  the  malignant  character  of  the  disease.  At 
this  date,  two  years  from  the  last  operation,  the  patient  is  living  and 
healthy. 

Lupus. — Lupus  erythematosus  and  vulgaris  usually  attack  the  tis- 
sues of  the  nose,  cheeks,  and  lips,  at  times  producing  extensive  loss  of 
substance.  The  erythematous  vai-iety  is  first  seen  as  small  red  papules, 
projecting  slightly  above  the  epidermis,  and  covered  with  scales.  It  is 
a  disease  of  the  sebaceous  glands  and  ducts,  causing  chronic  inflamma- 
tion of  the  skin  and  atrophy  of  all  the  elements  of  the  cutis.  Its  prog- 
ress is  slow,  and  the  prognosis  is  usually  favorable  when  the  disease  is 
confined  to  a  limited  area.  It  does  not  affect  the  general  health  of  the 
patient,  and  often  heals  spontaneously,  leaving  a  flat,  smooth  scar. 
When  disseminated  it  is  more  dangerous,  not  infrequently  ending  in 
fatal  complications.  The  treatment  requires  generous  diet,  tonics,  and 
out-of-door  life.  Among  the  local  agents  recommended  in  lupus  ery- 
thematosus is  green  soap,  which  should  be  spread  on  lint  and  pressed 
closely  upon  the  affected  part,  or  rubbed  in  with  the  finger  every  day. 
Prof.  A.  R.  Robinson,  in  addition  to  the  above,  also  recommends  a  10- 
per-cent  solution  of  oleate  of  mercury  brushed  over  the  diseased  surface. 

If  the  disease  does  not  yield  to  these  milder  measures,  the  sharp 
spoon  should  be  employed  and  the  broken-down  tissue  thoroughly 
scooped  out.  Emollients,  cold  applications,  or  poultices  may  be  used 
afterward,  according  to  the  requirements  of  the  case. 

Lupus  vulgaris  is  a  more  formidable  affection.  In  its  earlier  stages 
it  consists  of  a  number  of  soft  red  dots  in  the  deeper  layers  of  the  in- 
tegument, which  gradually  appear  as  papules  upon  the  surface.  The 
characteristic  lesion  is  the  infiltration  of  the  skin  with  an  abundant 
small  cell  new-growth.  It  is  believed  to  be  a  tuberculosis  of  the  skin. 
The  integument  breaks  down  and  is  cast  off  as  a  slough.  The  new- 
formed  cells  also  undergo  granular  metamorphosis,  and  disappear  with 
the  other  destroyed  tissues.  The  only  disease  likely  to  be  mistaken  for 
common  lupus  in  the  adult  is  epithelioma.  Lu]3us  begins  usually  in 
childhood,  while  epithelioma  is  exceedingly  rare  before  the  age  of  thirty. 


I 


THE  LIPS  AND   CHEEKS.  455 

The  ulcer  of  lupus  is  not  so  painful  as  that  of  epithelioma,  nor  its  edges 
so  hard  and  elevated.  The  treatment  of  this  affection  is  often  unavail- 
ing. The  constitutional  treatment  is  the  same  as  for  lupus  erythemato- 
sus. Locally,  a  10-per-cent  ointment  of  pyrogallic  acid,  spread  iipon 
linen  and  closely  laid  upon  the  diseased  surface,  is  a  useful  remedy.  It 
should  be  applied  twice  daily  for  several  days,  and  then  poultices  or 
ointments  iised  until  the  slough  is  removed.  In  certain  cases  it  is  ad- 
visable to  scrape  the  ulcer  well  with  the  sharp  spoon,  and  then  apply  the 
pyrogallic  acid  for  one  or  two  days. 

NcBvus. — As  has  been  stated  in  the  article  on  diseases  of  the  vascu- 
lar system,  arterial,  capillary,  and  cutaneous  vascular  tumors  are  occa- 
sionally located  upon  the  lips  and  cheeks,  and  reqxiire  removal  by  the 
knife,  ligature,  or  injection.  Their  excision  often  causes  extensive  loss 
of  tissue.  When  situated  in  the  free  border  of  the  lips  or  nares,  the 
50-per-cent  carboLic-acid  injection  should  be  tried  before  excision  is  prac- 
ticed. 

Moles  are  less  formidable,  and  rarely  require  an  extensive  reparative 
operation  after  excision. 

Papilloma,  lipoma,  adenoma,  and  fibroma  do  not,  as  a  rule,  require 
extensive  incisions  and  loss  of  tissue  in  their  removal. 

Cystic  tumors  of  the  lip  are  not  infrequent,  occurring  as  spherical 
swellings  beneath  the  mucous  membrane.  They  are  caused  by  obstruc- 
tion of  the  duct  of  a  labial  follicle,  and  contain  a  thick,  ropy  fluid.  The 
treatment  involves  a  careful  and  thorough  excision  of  the  sac. 

Fissiires,  or  ^'■chaps''''  of  the  lip  may  occur  independently  of  any 
constitutional  disease.  They  may  be  cured  by  a  local  astringent,  as 
alum,  or  caustic,  as  nitrate  of  silver,  a^Dplied  once  a  day  for  two  or  three 
days.  When  these  more  simple  remedies  are  without  avail,  excision 
should  be  x^racticed.  When  fissure  of  the  lip  is  allowed  to  remain,  and 
the  general  condition  of  the  patient  is  bad,  necrosis  of  the  mucous  mem- 
brane immediately  contiguous  ensues,  causing  a  grayish-red  ulcer.  The 
treatment  consists  in  the  local  use  of  astringents  and  the  improvement 
of  the  patient's  nutrition. 

Phlegmon  of  the  li]D  is  rare.  It  is  a  painful  and  dangerous  affection. 
The  pathology  of  carbuncle  has  been  given.  The  proper  treatment  is 
early  and  free  incision  through  the  skin,  deep  fascia,  and  muscles,  and 
frequent  irrigation  with  strong  sublimate  solution. 

Hypertropliy  of  the  lip  is  occasionally  met  \vitli.  It  may  be  confined 
to  the  mucous  and  submucous  tissues,  or  the  entire  thickness  of  the 
lip  may  be  involved.  It  occurs  usually  in  the  upper  lip,  but  may  be 
seen  occasionally  in  the  lower  lip.  When  extensive  enough  to  require 
operative  interference,  the  proper  method  is  to  dissect  out  in  the  long 
axis  of  the  lip  a  portion  of  the  tissue  between  the  skin  and  mucous 
membrane,  and  apjjroximate  the  edges  of  the  wound  with  silk  sutures. 

Hair  on  the  Lips  of  Woinen. — Permanent  epilation  may  be  effected 
by  introducing  into  the  follicle  of  each  hair  the  point  of  a  fine  platinum 
needle,  which  is  afterward  heated  by  the  galvanic  current.  The  employ- 
ment of  cocaine  renders  this  operation  painless. 


456 


A  TEXT-BOOK   ON   SURGERY. 


Reparative  Surgery  of  the  Lips. — A  plastic  operation  may  be  de- 
manded in  acquired  or  congenital  lack  of  tissne  in  the  upper  lip.  In 
the  lower  lip  congenital  deformity  is  exceedingly  rare. 

Hare-Lip. — Hare-lip  is  a  congen- 
ital defect  caused  by  an  arrest  of  de- 
velopment in  the  tissues  which  form 


I 


the  upper  lip.     Instead  of  uniting 
Fig.  454.  in  the  median  line,  a  fissure  exists 

which  may  include  either  the  soft 
structures  of  the  face  or  palate,  or  the  bones 
of  the  palate  as  well.     In  rare  instances  the  |:n  ^ 

cleavage  passes  up  into  the  eye  and  cranium 
(Figs.  454,  455).  The  fissure  is  usually  uni- 
lateral, and  may  be  so  small  that  it  is  scarcely 
noticed,  as  in  Fig.  456,  or  it  may  extend  half 
way  to  or  completely  into  the  nasal  cavity 
(Figs.  457,  458,  459).  One  side  of  the  lip  is 
much  thicker  than  the  other.  In  double  hare- 
lip the  fissures  are  about  the  same  distance 
from  the  median  line.  Both  may  extend 
into  the  nose,  or  one  (and  rarely  both)  may 
be  partial.     The  portion  intervening  may  be 


THE   LIPS    AXD    CHEEKS. 


45; 


composed  of  a  portion  of  the  lip  and  gnm,  with  one  or  more  rudi- 
mentary teeth,  at  a  varying  angle  of  projection.  The  central  piece 
occasionally  is  attached  to  the  nose.  In  incom^Dlete  single  hare-lip  the 
nostril  is  not  flattened  and  deformed,  as  is  the  case  when  the  fissnre 
extends  through  the  pre-maxillary  bone  and  the  palate  and  alveolar 
processes  of  the  superior  maxilla 
(Fig.  460).  The  location  of  this 
fissure  is  most  frequently  between 


Fig.  460. — (After  Koenig.) 


fiG.  461.— (After  Koenig.) 


the  first  and  second  incisor  teeth,  and  throngh  the  inter-maxillary  bone, 
and  not,  as  frequently  given  by  some  wi-iters,  between  the  second  in- 
cisor and  canine  teeth,  extending  backward  through  the  pre-maxillary 
suture. 

In  double  Tiare-Iip  the  cleft  in  the  palate  is  usually  double,  while  the 
center-piece  may  be  attached  to  the  vomer  (Fig.  461),  or  the  pre-maxil- 
lary portion  may  be  united  to  one  side  of  the  superior  maxilla  (Fig. 
460).  In  rare  instances  the  fissure  passes  obliquely  ujiward  and  out- 
ward, involving  the  eyelid,  orbit,  and  cranium,  producing  frightful  de- 
formity, as  shown  in  Fig.  4.55. 

Treatment.— Hh^  only  relief  from  this  deformity  is  in  a  plastic  opera- 
tion. It  should  be  done  early,  and,  when  possible,  within  the  first  few 
months  of  life.  Hearty  and  well-nourished  infants,  with  simjale  uni- 
lateral hare-lip,  should  be  operated  upon  at  birth.  If  they  are  feeble,  an 
effort  at  forced  nutrition  should  be  made,  and  the  operation  j^ostponed 
xmtil  the  patient  is  brought  into  proper  condition.  Double  or  single 
hare-lip,  with  cleft  palate,  should  be  operated  ui^on  early,  since  by 
drawing  the  lip  together  the  tension  on  the  superior  maxillary  bones 
facilitates  closure  of  the  interosseous  cleft. 

The  methods  of  operating  are  numerous.  The  essential  features  of 
eveiy  operation  are.  to  trim  the  edges  of  the  fissure  in  such  shape  that, 
when  they  are  approximated,  the  gap  will  be  closed  and  no  depression 
left  in  the  vermilion  border  of  the  lip. 

Single  Incomplete  Hare-Lip — First  MetTiod. — Having  estimated  the 
extent  of  surface  required  to  fill  up  the  deficiency,  with  a  long,  shai-ji 


458 


A  TEXT-BOOK   ON   SURGERY. 


FiQ.  462.— (After  Linliart.) 


knife  prick  the  integument  of  the  lip  at  a,  5,  c,  d,  and  e  (Pig.  462),  as 
guides  to  the  deep  incision.     Then  the  operator,  standing  in  the  position 
which  best  suits  his  convenience,  seizes  the  lip  between  his  thumb  and 
finger,   so  as   to   control    heemorrhage,   and, 
irlsi,  while  the  opposite  side  is  held  by  an  assist- 

ant, transfixes  it  at  a,  cuts  from  a  to  c,  by 
smooth,  short  strokes  of  the  knife,  removes 
and  reinserts  the  blade  at  d,  and  cuts  into  the 
angle  at  c.  This  manoeuvre  is  repeated  in  the 
line  a,  5,  e.  AVith  a  strong,  blunt  pair  of  scis- 
sors the  soft  tissues  are  freely  lifted  from  the 
bone,  until  the  edges  of  the  wound  can  be  ap- 
proximated without  any  degree  of  tension. 
If,  as  frequently  occurs,  one  side  is  so  much 
thicker  than  the  other  that  difficulty  is  expe- 
rienced in  keeping  the  approximated  edges  on  the  same  plane,  a  part  of 
the  under  surface  of  the  thicker  side  should  be  clipped  off  with  the  scis- 
sors. Strong  silver  hare-lip  jsins  (from  two  to 
four  in  number,  owing  to  the  length  of  the  in- 
cision) are  then  inserted,  being  made  to  enter 

about  one  fourth  of  an  inch  from  the  cut  edge,  _^^  ~^__ 

passing  through  the  entire  thickness  of  the  lip, 
and  out  at  a  corresponding  point  on  the  oppo- 
site side.  A  figure-of-8  silk  thread  is  wound 
about  these,  and  one  or  two  silk  sutures  are  in- 
serted, to  secure  a  perfect  approximation  at  all 
points.  The  pins  should  be  about  one  fourth  of 
an  inch  from  each  other,  and  the  lowest  should 
be  about  this  distance  from  the  vermilion  border, 
should  pass  through  the  vermilion  border  (Fig.  463). 

In  adults  a  light  loose  dressing  of  sublimate  gauze  will  suffice  in  the 
after-treatment.  In  children  it  is  always  wise  to  support  the  sutures  by 
narrow  strips  of  adhesive  plaster,  carried  from  the  angle  of  the  Jaw  across 
the  wound  to  the  opj)osite  side  of  the  face. 

The  pins  and  sutures  are  removed  between  the  third  and  fifth  days. 
No  rule  can  be  laid  down,  but  the  removal  should  be  made  as  soon  as 
union  has  taken  place.     For  the  few  days  im- 
jij  mediately  following  the  operation  the  muscles 

of  the  face  should  be  kept  as  quiet  as  possible. 
Silk  sutures  may  be  employed  if  the  pins  are 
not  at  hand.  When  the  fissure  is  wider,  the  an- 
gles b  and  c  should  be  made  deeper,  as  shown  in 
Fig.  464.  When  approximation  is  completed, 
c  and  h  unite,  while  the  points  d  and  e  project 
below  the  level  of  the  normal  li]3.  Any  re- 
Fie.  464.  dundancy  of  tissue  or  overlapping  should  be 

allowed  to  remain  until  all  shrinkage  has  oc- 
curred, when  the  excess  may  be  trimmed  off  at  the  level  of  the  lip. 


"■^^S 


f iQ.  4C3.— (After  Linhart.) 


The  last  suture 


THE  LIPS  AXD   CHEEKS. 


459 


Second  Method — Operation  of  Malgaigne. — With  a  shai-p  bistoury 
pare  the  edges  of  the  fissure,  by  cutting  a  strip  on  each  side,  from  the 
apex  down  to  about  one  eighth  of  an  inch  from  the  free  border  of  the  lip. 


Fig.  4G5. — (After  Malgaigne.) 


Fio.  466. — (After  Malgaigne.) 


The  strips  are  turned  down,  as  shown  in  Fig.  465,  and,  after  the  lip  on 
each  side  is  dissected  up  from  the  bone,  the  edges  are  approximated  and 
united,  as  shown  in  Fig.  466.  The  projecting  portion  is  treated  as  in  the 
preceding  operation. 

Third  Method — Operation  of  LangenhecJc. — Upon  one  side  of  the 
fissure,  as  at  b  (Fig.  467),  remove  a  narrow  strip  from  the  apex  out  through 


Fig.  467. — (After  Linhart,  Langenbeek.) 


Fig.  40S.— (Afttr  Linbart.') 


the  vermilion  border.  On  the  opposite  side,  «,  the  incision  extends  only 
to  within  one  eighth  to  one  fourth  of  an  inch  of  the  free  border.  After 
the  lip  is  freed  from  all  attachments,  the  edges  are  aiDjjroximated  and 
fastened,  as  shouTi  in  Fig.  468. 

Fourth  Method — Operation  of  Nelaton.- — Make  an  incision  parallel 


Fig.  469.— (After  Nelaton,  Koenig.) 


Fig.  470.— (After  Koenig.) 


460 


A  TEXT-BOOK  ON  SURGERY, 


with  the  upper  half  of  the  fissure,  on  either  side,  the  incision  arching 
over  the  apex,  as  shown  in  Fig.  469,  a  b.  When  completed  and  turned 
down,  a  diamond-  shaped  or  elliptical  opening  is  formed  (Fig.  470).  The 
pins  should  be  introduced  from  near  the  lateral  angles. 

Fifth  Method — Operation  of  Graefe. — Make  a  horseshoe-shaped  in- 
cision along  the  apex  of  the  fissure,  as  at  a  (Fig.  471),  and  remove  the 


Fig.  471.— (After  Koenig,  Graefe.)  Fig.  4T2. 

included  tissue  together  with  a  narrow  strip  along  the  edge  of  the  fissure 
on  one  side,  as  at  5,  through  the  free  border  of  the  lip.  Upon  the  op- 
posite side,  and  near  the  middle  of  the  fissure,  an  incision  through  the 
thickness  of  the  lip  is  made  in  a  direction  outward  and  slightly  down- 
ward, as  at  c.  In  approximating  the  edges  (see  Fig.  472),  the  receding 
angle  at  a  is  united  to  b  on  the  opposite  side,  and  the  tip  of  the  free 
border,  d,  is  stitched  to  c. 

The  modification  of  this  procedure  by  Koenig  is  preferable  in  cases 
where  the  gap  has  unusual  width  at  the  vermilion  border.  The  horse- 
shoe incision  at  a  is  the  same  as  in  the  preceding  operation,  but  there 


:  V     -n* 


Fig.  473.— (After  Koenig.) 


Fig.  474. — (After  Koenig.) 


are  two  lateral  horizontal  incisions,  2-2  (Fig.  473).  The  wound  has  the 
shape  shown  in  Fig.  474,  and  in  approximating  the  edges  the  apices 
of  the  two  flaps,  h  c  (Fig.  473),  are  brought  together  at  the  level  of  a 
(Fig.  474). 

Complete  Single  Hare- Lip — First  Method — Colles^s  Operation. — In 
certain  cases  where  the  fissure  is  of  great  width,  and  extends  through  the 
floor  of  the  nose,  important  modifications  of  the  foregoing  procedures  are 
at  times  necessary.  The  operation  is  one  of  considerable  difficulty,  not 
only  as  to  the  closure  of  the  fissure,  but  on  account  of  the  fiattening  of 
the  wing  of  the  nose  on  the  affected  side. 


THE  LIPS  AISTD  CHEEKS. 


461 


In  the  milder  cases  the  procedure  of  Colles  may  be  undertaken.  Upon 
one  side  of  the  fissure  (usually  the  most  perpendicular  surface  is  selected) 
make  an  incision  parallel  with  and  about  one  eighth  of  an  inch  from  its 
free  border,  a  c  (Fig.  475).  This  incision  terminates  short  of  the  wing  of 
the  nose  and  the  vermilion  border,  and  is  bisected  a  little  nearer  its  upper 
than  its  lower  end,  b.  The  opposite  surface  is  freshened  by  an  incision  in 
the  line  d  ef  (Fig.  475),  this  strip  being  entu-ely  removed.  When  the  soft 
parts  are  thoroughly  dissected  up,  the  edges  are  approximated,  so  that  the 
flap  5  c  is  turned  down,  and  its  end  is  stitched  to  the  line  ef.  The  flap 
&  a  is  turned  up,  its  freshened  surface  being  stitched  to  the  upper  part  of 
the  line  e  d,  while  its  upper  edge  looks  into  the  cavity  of  the  nostril. 


Fio.  475.— (After  Linbart,  Colics.) 


Fig.  476. — (Modified  from  Koenig.) 


Second  Method. — In  the  severer  forms  of  complete  unilateral  hare- 
lip, proceed  as  follows :  Freshen  the  edge  of  one  side  of  the  fissure  on 
the  line  indicated  by  &  a  (Fig.  476),  and  upon  the  opposite  side,  as  at  c  ^, 
from  d  making  a  division  of  the  lip  outward  and  downward,  d  e,  in  the 
direction  of  the  corner  of  the  mouth,  and  as  far  as  may  be  necessary. 
Dissect  up  the  tissues  freely  from  the  bones,  and  make  a  horizontal  in- 
cision on  either  side,  as  shown  atb  1,  c  1  (Fig.  476).  The  length  of  these 
incisions  will  depend  upon  the  degree  of  tension  required  to  bring  the 
flaps  into  apposition.  When  the  wing  of  the  nose  is  greatly  flattened 
the  defonnity  may  be  in  good  part  relieved  by  carrying  a  curved  incision, 
c2,  around  the  ala  nasi,  and  dissecting  loose  the  attachment  from  the 
maxillary  bone. 

Double  Hare-Lip. — The  method  of  operation  for  double  hare-lip  wiU 
depend  iipon  the  size  and  position  of  the  middle  jjiece,  and  the  width 


Fig.  477. — lAt'ter  Koenig.) 


Fig.  47o. -i^Alti;!    Koenig.) 


and  depth  of  the  lateral  fissures.     If  the  central  piece  is  so  prominent 
that  it  will  exercise  too  great  tension  upon  the  lip  when  the  sutures  are 


462 


A  TEXT-BOOK  ON  SURGERY. 


inserted,  the  bony  projection  should  be  seized  with  a  strong  forceps  and 
forced  back  into  a  safer  position,  or  broken  off  with  a  chisel.  The  edges 
of  the  central  tip  must  be  trimmed  or  freshened.  The  length  of  the  in- 
cision, a  h  (Fig.  477),  and  the  extent  of  the  dissection  of  the  lip  from  the 
jaw,  will  depend  upon  the  space  to  be  covered  in.  The  margin  from  a 
to  the  root  of  the  nose  is  not  freshened,  since  it  forms  the  iioor  of  the 
nostril  when  the  operation  is  completed.  The  condition  of  the  parts 
when  ready  for  the  sutures  (pins  are  not  used  where  a  central  piece  is 
preserved)  is  shown  in  Fig.  478.  The  points  h  h  meet  in  the  median  line 
of  the  lip,  while  a  a  are  sewed  to  the  central  piece. 

Cheiloplasty — Upper  Lip. — In  addition  to  congenital  deficiency  of 
the  lips,  not  infrequently  as  a  result  of  accident  or  disease,  or  the  re- 
moval of  abnormal  growths  or  cicatrices,  the  surgeon  is  called  upon  to 
relieve  the  deformity  and  inconvenience  resulting  from  this  loss  of  tissue. 

In  the  upper  lip,  when  the  loss  of  substance  is  not  extensive,  as  in 
Fig.  479,  the  unsightly  appearance  may  be  remedied  by  making  two  in- 
cisions, curved  as  represented  by  the  lines  ad,  ad,  from  the  side  of  each 


l"iG.  479.— (Attcr  Eoser.) 


Fig.  480.— (Alter  Koser.) 


ala  nasi  downward  and  inward  to  the  apex  of  the  fissure.  The  soft  tis- 
sues should  be  dissected  up  and  brought  into  position  by  sutures  applied 
as  in  Fig.  480.  If  after  the  dissection  the  tension  is  still  so  great  that  the 
parts  do  not  come  well  into  position,  a  horizontal  incision  should  be  made 
on  either  side,  beginning  near  the  root  of  the  nose,  and  carried  directly 

outward,  or  slightly  outward, 
"*  '  and  downward,  as  the  shape  of 

the  flap  may  require.  Where 
there  is  greater  loss  of  sub- 
stance, Burrows's  method  is 
advisable  (Fig.  481).  Make  a 
horizontal  incision  on  each  side, 
commencing  in  the  angle  of 
the  mouth,  and  going  entirely 
through  the  lip,  ah,  c  d,  and 
unite  these  at  Jc  and  j.  Dis- 
sect out  the  triangular  piece. 
j  ah,  Jc  c  d.  Make  now  two 
other  horizontal  incisions,  which 
run  into  the  nasal  cavity  g  Ti 
and  /  e,  and  dissect  out  two  smaller  triangles,  fern,  and  g  7i  I.  The 
proximal  edges  of  the  quadrilateral  flaps  gTicd  and  efah  should  now 


Fig.  481.— (After  Linhart.) 


THE   LIPS   AND   CHEEKS. 


463 


be  freshened  and  freely  lifted  by  dissection,  and  the  sutures  intro- 
duced. It  will  be  observed  that  as  the  edges  are  approximated,  the 
lines  dli,  hj\  mf,  and  Ih,  will  be  imited  with  cJc,  aj,  me,  and  I g. 

A  third  method,  which  is  useful  in 
certain  cases,  is  as  follows  :   After  the  ^_ 

disease  is  removed,  an  incision,  c  a 
(Fig.  482),  is  earned  from  the  alse  of 
the  nose  upward  and  outward.  The 
length  of  this  cut  and  its  obliquity  de- 
pend upon  the  distance  to  be  filled  be- 
tween the  normal  line  of  the  lip  and 
the  nose.  A  second  incision,  a  i,  is 
now  carried  deeply  downward  and  out- 
ward, making  a  quadrilateral  flap, 
which  hinges  at  b  d,  and  is  dissected 
up,  and  the  edges,  c  a,  are  brought  in 
apposition  and  secured  in  the  median 
line. 

Lower  Lip. — When  the  loss  of  tissue  has  left  a  cavity  triangular  in 
shape,  as  in  Fig.  483,  that  one  of  the  following  methods  may  be  selected 
which  in  the  judgment  of  the  opera- 
tor is  best  adapted  to  the  case  : 


Fig.  482.— {After  Linhart.) 


Flo.  483. — (After  Szymanowsky.) 


Fig.  484.— (After  Linhart.) 


1.  A  horizontal  cut,  a  h  (Fig.  484), 
is  made  outward  from  the  angle  of 
the  lip,  and  a  second  one,  &  c,  parallel 

with  the  freshened  edge  of  the  fissure.     Both  flaps  are  now  loosened  and 
slid  toward  the  median  line,  and  united  by  pins  or  sutures.     Along  the 
free  border  of  the  new  lip  stitch  the  mu- 
cous membrane  to  the  skin  with  fine  silk 
sutures.    The  gap  left  on  either  side  is  also 
wholly  or  partially  closed  by  sutures. 

2.  For  the  same  defect  make  a  semi- 
circular incision  outward  and  downward 
from  each  angle  of  the  mouth,  cgd  and 
afe  (Fig.  485).  Dissect  this  flap  up  freely 
and  slide  toward  the  middle  line.  The  pin- 
sutures  are  inserted  as  in  Fig.  486,  taking         fig.  4S5.— (After  Szymanowsky.) 


464 


A  TEXT-BOOK   ON  SURGERY. 


4. 
from 


/  \  the  precaution  to  sew  the  mucous  membrane 

v^»'<s-.^  /      to  the  integument  along  the  edge  of  the 

newly  made  lip. 

3.  If  the  fissure  is  less  extensive,  make  a 
horizontal  incision  from  each  angle  of  the 
mouth  through  the  entire  thickness  of  the 
lip  for  a  sufficient  distance  (Fig.  487),  a  e, 
c  d,  dissect  up  the  triangular  flaps,  and  ad- 
just with  pin-sutures,  as  shown  in  Fig.  488. 
When  the  apex  of  the  triangular  defect  does  not  dip  down  too  far 
the  teeth,  the  unilateral  sliding  operation  of  Blasius  may  be  prac- 


486.— (After  Szymanowsky.) 


Fio.  487. — (After  Szymanowsky.) 


Fig.  488. — (After  Szymanowsky.) 


ticed.  From  the  apex  of  the  angle,  c  (Fig.  489),  make  a  deep  cut,  ced, 
downward  and  outward  over  the  side  of  the  chin,  in  the  main  a  continu- 
ation of  the  line  of  the  defect,  hfc. 
The  flap,  aced,  is  dissected  up  and 
slid  so  that  c  is  attached  to  5  (Fig.  490). 
5.  When  the  defect  extends  in  the 
shape  of  an  isosceles  triangle  with  the 
apex  low  down  upon  the  chin,  the 
method  of  Burrows  (Fig.  491)  is  ap- 


FiG.  489. — (After  Szymanowsky.) 


Fio.  490.— (After  Szymanowsky.) 


Fig.  491.— (After  Linhart.) 


plicable.     Two  triangular  pieces,  afJi,  hgTc,  are  removed  from  the  tis- 
sues just  above  the  angles  of  the  mouth.     The  edges  of  the  fissure  are 


THE   LIPS   AND    CHEEKS. 


465 


freshened,  the  ^a.-ps,  f  a  d  g  b  d,  dissected  loose,  and  the  lines,  ac,  he, 
approximated  by  sutures. 

6.  When  the  defect  is  long  and  rectangular,  as  shown  in  Fig.  492,  the 
procedure  of  Von  Bruns  may  be  successf  ally  employed.  The  diseased 
tissue  being  removed,  the  quadrilateral  flaps,  abed  (Fig.  493),  are  dis- 


FiG.  492.— (Aft«r  Linhart.) 


Fig.  493.— (After  Linhart.) 


sected  out  and  brought  down,  uniting  e  b  in  the  median  line  and  a  b  on 
either  side  to  the  line  a  a.  The  defect  left  on  both  sides  of  the  outer 
aspect  of  the  upper  lip  may  be  wholly  or  in  great  part  closed  by  sutures. 
The  outer  incision  should  not  be  carried  far  enough  back  to  wound  the 
duct  of  Steno. 

7.  Or  the  flaps  may  be  turned  from  below,  as  advised  by  Sedillot 
(Fig.  494).  The  inferior  obliqixe  lines  are  carried  to  the  middle  line  and 
stitched  to  each  other.     The  defect  is  closed  by  sutui-es  (Fig.  495). 


Fig.  494.— (After  ilalgaigne.) 


Fig.  495.— (After  ilalgaigne.) 


CJieeks. — When  the  loss  of  substance  is  not  extensive,  the  edges  may 
be  dissected  up  to  a  limited  extent,  pared,  and  brought  directly  together 
by  sutures.     If  this  can  not  be  accomplished,  incisions  shaped  as  sho'^\Ti 
30 


466 


A  TEXT-BOOK   ON  SURGERY. 


in  Fig.  496  (Miitter's  method),  ai,  ae,  maj'-  be  made,  the  flaps  lifted,  and 
brought  together  by  sutures.  The  gaps  left  above  and  below  may  be 
also  closed  at  once. 

Sliding  a  flap  from  the  neck  is  shown  in  Fig.  497,  where  the  flap, 
bad,  is  brought  up  to  fill  the  oval  space  left •  by  removal  of  the  diseased 


Fig.  496.— (After  Eoser.) 


Fig.  497. — (After  Malgaigae.) 


tissue,  tea.  The  pedicle  is  divided  as  soon  as  union  has  occurred,  and 
the  stump  returned,  as  in  rhinoplasty. 

In  contraction  of  the  mouth  the  orifice  may  be  enlarged  by  incising 
the  angles  in  a  horizontal  direction,  finishing  the  operation  by  stitching 
the  skin  and  mucous  membrane  together.  Or  an  elastic  ligature  may  be 
introduced  through  the  cheek  at  the  required  distance  from  the  angle, 
brought  out  at  the  corner  of  the  mouth,  and  tied.  During  the  slow  pro- 
cess of  cutting  through,  the  track  of  the  wound  becomes  covered  with 
ej)ithelia,  and  reunion  is  prevented. 

In  the  selection  of  any  of  the  plastic  methods  heretofore  given,  the 
surgeon  must  be  guided  by  the  requirements  of  each  case.  It  is  a  wise 
precaution  to  make  a  guarded  prognosis,  for,  no  matter  how  successful 
from  the  surgical  standpoint,  the  operations  do  not,  in  the  majority  of 
instances,  secure  the  expected  improvement  in  the  personal  appearance 
of  the  patient. 

Paeotid  Gland  and  Duct. 


Salivary  fistula  may  be  confined  to  the  main  parotid  duct  in  any  part 
of  its  course,  or  to  the  primary  ducts  within  the  substance. of  the  gland. 

It  may  result  from  a  wound  or  any  inflammatory  and  necrotic  process 
due  to  obstruction  from  salivary  calculi  or  other  disease  of  the  parotid 
and  buccal  regions.  Exploration  of  the  duct  with  a  delicate  blunt  probe 
is  accomplished  thus :  Find  the  outlet  at  the  papilla  on  the  mucous 
membrane  of  the  buccal  cavity  near  the  junction  of  the  second  bicuspid 


PAROTID   GLAXD   AND  DUCT.  467 

and  first  molar  teeth,  of  the  upper  jaw.  Introduce  the  probe,  carrying  it 
at  first  slightly  outward.  When  it  is  arrested  by  the  natural  curve  of  the 
duct,  pull  the  corner  of  the  mouth  and  the  cheek  directly  outward,  thus 
straightening  the  tube.  The  general  direction  is  backward,  toAvard  the 
auditory  meatus. 

The  diagnosis  of  salivary  fistula  or  of  obstructed  duct  may  be  deter- 
mined as  follows :  By  means  of  absorbent  cotton  or  lint  remove  all 
moisture  from  the  mucous  surface  where  the  papilla  is  situated,  and  place 
some  sapid  or  acid  substance  on  the  tongue.  If  there  is  no  obsti'uction, 
the  flow  of  saliva  is  immediately  perceived.  In  case  of  fistula  the  secre- 
tion will  flow  out  through  it.  Calculi  of  Steno's  duct,  or  of  any  of  the 
salivary  ducts,  should  be  removed  by  dilatation,  if  this  is  possible,  and 
if  not,  by  incision. 

In  the  treatment  of  salivary  fistula  the  object  aimed  at  is  to  stop  the 
flow  of  saliva  on  the  outside  and  turn  it  into  the  mouth.  Arm  a  probe 
with  a  silk  seton  and  carry  it  through  the  fistula  into  the  buccal  cavity, 
bring  the  thread  out  through  the  mouth,  and  tie  the  two  ends  together. 
In  about  ten  days  the  flow  into  the  mouth  will  be  fully  established, 
when  the  seton  should  be  removed  and  the  outer  opening  closed  by  a 
compress  until  cicatrization  occurs.  It  may,  at  times,  be  necessary  to 
freshen  the  edges  and  bring  them  together  with  a  suture. 

Riberi  operated  successfully  by  cutting  through  the  integument 
down  upon  the  duct  behind  the  opening,  passing  a  ligature  around  it, 
and  carrying  this  and  the  end  of  the  duct  into  the  buccal  cavity  where 
it  was  left  open.  The  wound  in  the  integument  was  immediately  su- 
tured. 

In  a  case  recently  treated  by  the  author,  the  following  method  was 
successful  in  restoring  the  integTity  of  the  flow  of  saliva  into  the  mouth : 
A  boy  twelve  years  old  had  scarlatina  at  seven,  which  was  followed  by 
obsti'uction  of  the  left  duct  of  Steno.  A  fistulous  opening  occurred 
spontaneously  behind  the  ear.  Cutting  down  through  the  cheek  in  the 
anatomical  line  of  the  duct,  this  was  discovered  to  be  obliterated  for 
the  last  half-inch  of  its  course.  It  was  divided  just  posterior  to  the 
limit  of  occlusion,  and  an  incision  opposite  this  point  made  directly 
through  into  the  buccal  cavity.  Two  fine  silk  threads  were  inserted  in 
the  wall  of  the  duct  at  the  end,  and  these  sutures  were  stitched  to  the 
mucous  membrane  of  the  cheek  at  the  edges  of  the  incision  just  made. 
The  wound  in  the  integument  of  the  face  was  closed,  excepting  the 
anterior  angle,  where  a  small  rubber  tube  was  inserted.  This  tube  pro- 
jected into  the  cavity  of  the  mouth  by  the  side  of  the  new  opening  for 
the  duct.  This  was  done  to  form  a  fistula  in  case  the  wound  in  the  mu- 
cous membrane  should  close  and  obstruct  the  duct.  A  compress  was 
placed  and  worn  on  the  fistulous  opening  behind  the  ear.  The  tube 
was  removed  in  five  weeks,  and  the  external  outlet  closed  by  silk  sut- 
ures. At  this  time,  also,  the  old  fistulous  opening  was  closed.  The 
saliva  up  to  this  time  flowed  about  equally  out  of  the  hole  behind  the 
ear  and  the  opening  in  front.  After  this  it  came  only  through  the  end 
of  the  duct  in  the  mouth. 


468  A  TEXT-BOOK  ON  SURGERY. 

Fistula  of  the  primary  ducts  within  the  substance  of  the  gland  may- 
require  the  forced  atrophy  or  ablation  of  this  organ.  An  effort  at 
occlusion  should  be  made  by  direct  pressure  upon  the  abnormal  opening, 
or  by  careful  dissection  in  the  line  of  the  fistula,  when  this  can  be  safely 
done.  When,  however,  the  fistulous  tract  is  deeply  situated,  it  will  be 
found  almost  impossible  to  effect  a  cure  without  serious  risk  of  interfer- 
ing with  the  integrity  of  the  seventh  nerve,  the  motor  filaments  of  which 
are  in  intimate  relation  with  this  gland.  Removal  of  the  parotid  gland, 
for  any  cause,  becomes  a  serious  operation,  since  it  necessarily  implies 
paralysis,  more  or  less  complete,  of  the  muscles  of  the  face  ;  when  it  is  en- 
tertained, the  patient  should  be  thoroughly  acquainted  with  the  prospect 
of  paralysis  which  will  follow.  In  non-malignant  cases  the  greatest  care 
should  be  exercised  in  avoiding  division  of  the  filaments  of  the  facial 
nerve.  Even  in  the  arrest  of  haemorrhage,  as  the  operation  proceeds,  the 
application  of  the  forcej)S  should  be  carefully  made,  so  that  the  branches 
of  the  nerve  may  not  be  injured  or  included  in  the  ligature.  When  the 
seat  of  malignant  disease,  a  thorough  ablation  is  essential,  and  the  nerve 
is  necessarily  sacrificed. 

Tumors  of  tlie  Parotid. — About  30  per  cent  of  all  neoplasms  of  this 
organ  are  enchondromata,  25  carcinomata,  while  the  remaining  45  per 
cent  are  about  equally  divided  between  sarcomata,  fibromata,  myxomata, 
and  cystomata.  Simple  hypertrophy  is  rare,  although  hyperplasia  of 
the  gland-tissue  occurs  in  a  varying  degree  in  the  progress  of  most  of 
the  neoplasms  which  attack  this  organ. 

Tumor  of  the  parotid  is  rare  yjrior  to  the  thirtieth  year  of  life,  being 
met  with  chiefly  between  the  thirtieth  and  fiftieth  years.  As  to  the 
period  when  the  various  forms  appear,  it  may  be  said  that  carcinoma 
occurs  generally  after  the  fiftieth  year,  while  enchondroma,  sarcoma, 
myxoma,  and  fibroma  develop  in  the  earlier  decades.  Sarcoma  is  apt  to 
develop  in  childhood  or  early  adult  life. 

Diagnosis. — All  forms  of  tumor  of  the  parotid,  as  a  rule,  develop 
slowly.  In  the  earlier  stages  of  their  development  they  are  movable 
within  the  limited  area  of  mobility  of  the  gland.  This  is  true  of  both 
the  benign  and  malignant  growths.  Later,  even  the  benign  neoplasms 
may  become  fastened  between  the  temporal  bone  and  fascia  and  the 
ramus  of  the  jaw,  but  not  to  the  overlying  integument.  The  malignant 
growths  are  more  rapid  in  development,  and  earlier  in  their  history  are 
bound  down  to  the  surrounding  tissues,  may  become  adherent  to  the 
integument,  and  produce  great  pain  and  disturbance  by  reason  of 
pressure  upon  the  nerves  and  vessels  with  which  the  gland  is  in  close 
relation. 

The  cartilage  tumors  are  nodular,  hard,  and  slightly  elastic  to  direct 
pressure.  Cancer  is  also  nodular  at  times,  but  not  so  hard  as  enchon- 
droma. Cancer  comes,  as  a  rule,  after  the  forty-fifth  to  fiftieth  year, 
and  the  other  neoplasms  before  this  period.  The  lymphatic  glands  are 
involved  in  cancer,  and  rarely  enlarged  in  any  other  form  of  neoplasm. 
Sarcoma  occurs  earliest  of  all.  Cysts  are  elastic,  may  present  fluctua- 
tion, while  the   exact   character  of  this  variety  may  be  determined  by 


PAROTID   GLAXD   AND   DUCT.  469 

exploration  witli  tlie  aspirator.  If  of  great  importance  in  determining 
the  plan  of  treatment  to  be  pnrsued,  a  section  of  the  diseased  organ 
sutficiently  large  for  microscopic  examination  should  be  remoTed  ;  in 
this  way  a  positive  diagnosis  is  assured. 

Removal  of  the  parotid  gland  is  one  of  the  most  difficult  operations 
in  surgery.  In  many  cases  of  tumor  of  this  organ  in  which  the  neo- 
plasm is  developed  at  the  expense  of  the  under  jjortion  of  the  gland, 
the  internal  jugular  vein,  internal  carotid  artery,  and  the  important 
nerves  and  ganglia  situated  here  become  so  involved  that  complete  ex- 
tirpation is  impossible  during  life.  This  condition  was  found  to  exist  in 
a  case  in  which  I  removed  all  of  the  organ  anterior  to  the  deep  vessels. 
Having  at  first  tied  the  external  carotid  arterj',  the  dissection  was  com- 
paratively bloodless.  When  the  tumor  is  of  smaU  size,  it  may  be  en- 
tirely removed.  Section  of  the  various  di'visions  of  the  facial  nerve  or 
of  the  main  trunk  is  almost  inevitable.  In  a  patient  in  whom  both 
parotids  were  removed  by  the  author  for  large  carcinomata,  with  an  inter- 
val of  about  six  weeks,  both  external  carotids  were  tied.  The  facial 
paralysis  was  at  first  complete,  but  after  two  years  there  was  marked 
improvement  in  motion  of  the  face-muscles.  Recurrence  took  place  after 
three  years  on  both  sides,  and  further  operation  was  not  advised.  If  the 
externa]  carotid  is  first  secured,  it  may  be  avoided  by  a  careful  dissec- 
tion, provided  that  the  tumor  is  of  moderate  size. 

Operation. — Make  a  crucial  incision  over  the  mass,  the  perpendicular 
cut  being  in  the  line  of  the  external  carotid  artery.  Turn  the  Haps 
back  from  the  anterior  aspect  of  the  tumor,  and  approach  its  deeper 
portions  from  below  in  the  line  of  the  vessels.  As  soon  as  the  external 
carotid  can  be  exposed,  it  should  be  secured  with  a  catgut  ligature.  All 
bleeding  should  be  arrested  as  the  operation  proceeds.  In  lifting  the 
under  surface  of  the  tumor  from  its  bed,  the  operator  should  keep  close 
to  the  mass,  using  a  dull  instrument  for  fear  of  wounding  the  internal 
jugular  vein  and  other  important  vessels  or  nerves.  The  blunt  scissors 
curved  on  the  flat,  the  handle  of  the  scalpel,  or  the  thumb  and  finger- 
nail may  be  utilized  for  this  purpose.  The  facial  nerve  and  its  branches 
which  run  through  the  neoplasm  should  be  saved,  if  jjossible.  As  before 
stated,  if  the  tumor  is  extensive,  this  is  scarcely  possible  on  account  of 
the  great  length  of  time  it  would  require.  If,  in  the  course  of  the  opera- 
tion, it  is  discovered  that  the  neoplasm  dips  down  beneath  the  jaw  and 
styloid  process,  and  surrounds  the  vessels  and  nerves,  its  complete  ex- 
tirpation is  impossible.  As  much  of  the  mass  as  can  be  lifted  shoiild 
now  be  transfixed  near  the  middle  with,  a  double  elastic  ligature,  tied, 
and  the  part  external  to  the  ligature  cut  away. 

The  prognosis  in  cancer  and  sarcoma  of  the  parotid  is  always  grave, 
even  after  removal.  .  The  anatomical  relations  of  this  organ  are  such 
that  a  wide  and  complete  extii'pation,  such  as  is  readily  made  in  tumors 
of  the  breast,  is  impossible.  The  question  will  natiu'ally  arise.  I'nder 
what  conditions  should  the  operation  be  advised  and  itndertaken  ;  In 
malignant  disease  the  propriety  of  extirpation  is  very  questionable,  and 
should  only  be  undertaken  after  a  clear  explanation  of  the  dangers  of 


470  A  TEXT-BOOK   ON  SUEGERY. 

the  operation  and  the  probabilities  of  recurrence.  In  benign  tumors 
which  show  a  tendency  to  increase,  operation  may  be  advised,  especially 
if  the  tumor  is  still  of  small  size.  It  is  always  important  to  attempt  the 
removal  of  the  neoplasm  early  in  its  history.  Facial  paralysis  generally 
follows  the  operation,  and  is  more  or  less  permanent. 


Parotitis — "Mumps." 

Inflammation  of  the  parotid  gland  occurs  chiefly  in  children,  but  is 
occasionally  met  with  in  adults.  In  males  it  is,  at  times,  accompanied 
by  orchitis,  and  in  females  the  mammary  glands  and  ovaries  are  affected. 
The  symptoms  are  pain  and  swelling  of  the  gland,  difficult  deglutition, 
and  slight  febrile  movement.  The  prognosis  is  favorable,  the  disease 
yielding  to  warm  applications,  quiet,  and  the  judicious  employment  of 
laxatives.  In  rare  instances  atrophy  of  the  testicle  has  been  known  to 
follow  the  inflammation  of  this  organ,  occurring  as  a  complication  of 

Abscess  may  occur  after  an  acute  inflammation  of  the  parotid  from 
traumatism,  or  as  a  complication  of  the  eruptive  or  continued  fevers. 
Under  these  last  conditions  the  prognosis  is  always  grave.  The  presence 
of  pus  is  recognized  by  the  intense  character  of  the  pain  experienced, 
the  febrile  movement,  the  doughy  condition  of  the  skin  and  areolar 
tissue  in  front  of  the  organ,  and  by  aspiration.  The  abscess  should  be 
evacuated  by  aspiration,  puncture,  or  incision. 


Submaxillary  Gland. 

This  organ  may  become  inflamed  and  suppurate,  or  be  the  seat  of 
neoplasms,  yet  not  so  frequently  brought  to  the  attention  of  the  sur- 
geon as  the  parotid.  Its  removal  is  a  simple  procedure,  and  may  be 
accomplished  by  a  crescentic  incision  commencing  at  the  angle  of  the 
jaw,  dipping  three  quarters  of  an  inch  toward  the  hyoid  bone,  and  end- 
ing one  and  a  half  inches  in  front  of  the  angle  at  the  lower  border  of  the 
jaw.  The  flap  of  skin  should  be  raised  with  the  platysma  muscle  as  far 
as  the  jaw,  and  the  deep  cervical  fascia  divided.  The  gland  rests  be- 
neath and  internal  to  the  bone  and  upon  the  mylohyoid  and  hyoglossus 
muscles.     The  submaxillary  branch  of  the  facial  artery  will  be  divided. 

The  Jaws. 

Siiperior  Maxilla.  — Periostitis,  ostitis,  and  abscess  of  the  upper  jaw 
may  be  caused  by  caries  of  the  teeth,  disease  of  the  upper  jaw  within 
the  antrum,  or  pathological  changes  within  the  bone  proper.  Ostitis  of 
the  maxilla  is  more  apt  to  occiir  in  children,  and  especially  in  those  of  a 
strumous  diathesis.  Phosphorus-poisoning  and  the  syphilitic  dyscrasia 
lead  also  to  inflammation  and  caries  of  this  bone. 

The  symptoms  of  ostitis  and  abscess  here  do  not  difl'er  from  those 


THE  JAWS.  471 

already  given  in  the  general  chapter  on  bone  diseases.  Pain  is,  perhaps, 
more  acute  in  ostitis  within  the  distribution  of  the  trifacial  nerve.  It  is 
elicited  by  direct  pressure,  and,  when  the  process  is  associated  with  a 
carious  tooth  or  its  roots,  the  exact  location  may  be  determined  by 
striking  the  tooth  sharply  with  a  metallic  substance. 

The  treatment  is  to  relieve  the  tension  by  puncture  or  incision,  or 
by  extraction  of  one  or  more  teeth  in  case  they  are  connected  with  the 
diseased  surface.  The  removal  of  dead  bone  is  demanded,  although  it  is 
wise  not  to  operate  too  early.  When  exfoliation  has  occiirred,  the  oper- 
ation is  much  simplified.  If  free  drainage  is  secured  by  early  incision, 
the  arrest  of  the  spread  of  the  disease  is  practically  insured.  Chronic 
alveolar  abscess  is  often  cured  by  extraction  of  an  offending  tooth. 
When  this  fails,  the  diseased  surface  should  be  exposed  by  incision,  and 
a  thorough  removal  accomplished.  When  possible,  all  sequestra  should 
be  removed  from  within  the  oval  cavity  in  order  to  avoid  a  scar  upon  the 
face. 

Syphilitic  ostitis,  and  that  variety  which  occurs  from  absorption  of 
the  fumes  of  phosphorus,  require  specific  constitutional  treatment  as 
well  as  operative  interference. 

Abscess  of  the  antrum  of  Highmore  may  occur  as  the  result  of  an 
Inflammatory  process  in  the  mucous  membrane  lining  this  cavity,  or  in 
connection  with  ostitis  of  the  upper  jaw,  or  from  the  presence  of  foreign 
bodies  or  neoplasms  within  its  cavity.  The  chief  symptom  is  pain,  re- 
ferred to  the  region  of  the  antrum.  The  febrile  movement  of  acute  ab- 
scess is  usually  present.  The  pus  may  force  its  way  through  the  open- 
ing into  the  meatus,  or  cause  necrosis  in  the  bone  and  discharge  in  any 
direction. 

Treatment. — Free  drainage  must  be  established  in  all  cases.  The 
extraction  of  the  first  or  second  molar  and  the  application  of  a  drill  to 
enlarge  the  opening  may  suffice.  If  necessary,  a  portion  of  the  alveolar 
process  should  be  gnawed  away  with  the  forceps.  In  extreme  cases  an 
incision  should  be  made  through  the  skin  just  above  the  situation  of  the 
first  molar  tooth,  and  a  thorough  opening  made  with  a  trephine  or 
gouge.  It  is  important  to  explore  the  cavity  with  the  finger  in  order  to 
determine  the  presence  of  dead  bone  or  any  ofl'ending  substance.  Free 
drainage  must  be  maintained  untU  recovery  is  secured.  In  a  case  which 
came  under  my  observation,  I  found  the  cause  of  an  abscess  of  thii'teen 
years'  duration  to  be  a  supernumerary  molar  tooth  which  was  lying 
loose  in  the  antrum. 

The  same  operation  will  be  most  essential  in  those  cases  of  hydrops 
antri,  or  retention  of  fluid,  and  in  the  cure  of  cysts  of  this  cavity. 

Among  the  many  other  diseases  to  which  the  antrum  is  subject  are 
myxoma,  fibroma,  papilloma,  sarcoma,  carcinoma,  and  various  hyperos- 
toses. The  differentiation  of  these  growths  is  extremely  difficult,  and, 
when  doubt  exists  as  to  the  character  of  the  neoi^lasm,  an  exploratory 
operation  for  the  purpose  of  positive  diagnosis  should  be  made.  This 
is  done  by  applying  the  trephine  as  just  given. 

Non-malignant  new  formations  may  be  removed  by  an  osteoplastic 


47^  A  TEXT-BOOK   ON   SURGERY. 

operation,  while  malignant  growths  often  require  the  sacrifice  of   the 
entire  upper  jaw. 

Osteoplastia  Operation  for  Itemoval  of  Benign  Tumor  from  the  An- 
trum of  Highmore — Langenheck's  Procedure. — From  the  junction  of 
the  wing  of  the  nose  with  the  lip  an  incision  is  carried  outward  parallel 
with  the  level  of  the  teeth,  and  is  made  to  divide  the  soft  parts  to  the 
bone  as  far  as  the  center  of  the  malar  prominence,  where  it  is  curved  up- 
ward and  inward,  ending  a  quarter  of  an  inch  below  the  outer  angle  of 
the  orbit.  This  is  joined  by  a  second  incision,  which  is  commenced  about 
a  quarter  of  an  inch  below  the  level  of  the  orbit  at  the  suture  between 
the  nasal  bone  and  the  nasal  process  of  the  superior  maxUla,  and  is  car- 
ried outward  parallel  with  the  lower  margin  of  the  orbital  cavity. 

The  tissues  must  not  be  lifted  from  the  periosteum  within  this  curved 
incision.  The  hsemorrhage,  which  is  always  sharp,  being  arrested,  with 
a  blunt  instrument  carefully  lift  the  eye  from  the  floor  of  the  orbital 
cavity  until  the  finger  can  be  carried  into  the  anterior  portion  of  the 
spheno-maxUlary  fissure.  With  this  as  a  guide,  insert  a  small,  strong 
key-hole  saw  into  the  fissure  and  divide  the  ma- 
lar bone  outward  in  the  line  of  the  incision  (see 
Fig.  498).  In  moving  the  saw,  keep  the  blade 
perpendicular,  and.  limit  the  motion  so  that  the 
point  may  not  penetrate  the  temporal  fossa  and 
wound  the  vessels.  Next  insert  the  saw  in  the 
lower  horizontal  incision  and  divide  the  supe- 
rior maxilla  into  the  cavity  of  the  antrum  and 
nose.  In  sawing  on  this  line,  keep  the  mouth 
open  and  the  finger  inserted  behind  the  palate  to 
prevent  the  point  of  the  instrument  from  j)enetrating  too  far  back.  The 
nasal  process  of  the  superior  maxilla  is  now  divided  with  a  chisel  at  a 
point  half  way  between  the  inferior  orbital  foramen  and  the  inner  angle 
of  the  orbit.  The  cutting-edge  of  the  chisel  should  be  directed  slightly 
outward  for  fear  of  injuring  the  lachrymo-nasal  duct.  The  lines  of  sec- 
tion in  the  bones  are  shown  in  Fig.  498.  The  point  of  exit  of  the  infra- 
orbital nerve  should  be  foxmd  and  this  branch  of  the  trifacial  divided  at 
the  foramen.  An  elevator  is  now  placed  in  the  fissure  made  by  the  saw 
through  the  malar  bone  and  the  mass  dislocated  inward,  hinging  on  the 
undivided  soft  tissues.  This  force  fractures  the  floor  of  the  orbit  and 
opens  widely  the  antrum  of  Highmore.  When  the  operation  is  finished, 
the  bone  is  neatly  replaced  and  the  edges  of  the  wound  accurately  ad- 
justed. Drainage  may  be  secured  through  the  wound,  or  a  hole  may  be 
drilled  through  the  edge  of  the  alveolus.  This  same  operation  is  advis- 
able in  section  of  the  second  branch  of  the  fifth  nerve  and  extirpation  of 
Meckel's  ganglion.  When  the  ganglion  is  the  objective  jjoint,  it  may  be 
found  by  following  the  superior  maxUlary  branch  of  the  fifth  nerve 
along  the  floor  of  the  orbit  to  the  location  of  the  ganglion  on  the  an- 
terior surface  of  the  pterygoid  process  of  the  sphenoid  bone.  The 
posterior  shell  of  the  antrum  must  be  broken  through  in  order  to  enter 
the  fossa. 


REMOVAL   OF   THE   UPPER   JAW. 


473 


Opeeatiox  for  Removal  of  the  Upper  Ja^v. 

A  quarter  of  an  inch  below  the  inner  canthus  of  the  eye  commence  an 
incision  and  carry  it  doTv-nward  along  the  naso-maxillary  groove,  curving 
in  the  contour  of  the  ala  nasi,  then  horizontally  beneath  the  ala  to  the 
median  line  of  the  lip,  where  it  turns  directly  downward,  dividing  the 
lip  in  the  median  fissure.  From  the  point  of  beginning  carry  a  second 
incision  one  fourth  of  an  inch  below  and  parallel  with  the  inferior  mar- 
gin of  the  orbit  out  to  the  prominence  of  the 
malar  bone  (Fig.  499).  Dissect  up  the  soft  tis- 
sues of  the  cheek,  and  turn  the  flap  downward 
and  outward.  If  the  disease  is  so  extensive 
that  the  incision  does  not  expose  the  parts 
sufficiently,  a  horizontal  cut  may  be  made  out- 
ward from  the  angle  of  the  mouth. 

The  bone  may  be  divided  by  the  saw  insert- 
ed in  the  spheno-maxillary  fissure,  as  in  the 
preceding  operation,  cutting  through  the  nasal 
process  with  a  chisel.  Extract  an  incisor  tooth, 
and  -i^-ith  large,  strong  bone-cutting  forceps  di- 
vide the  alveolus  and  the  palate-process  by  in- 
serting one  blade  in  the  nose  and  the  other  in 
the  mouth.  These  sections  being  accomplished, 
avulsion  is  made  by  means  of  elevator  and  for- 
ceps. The  operation  is  completed  by  the  clos- 
ure of  the  wounds  with  fine  silk  sutures.  If,  in  section  of  the  palate, 
the  Paquelin  cautery  is  used,  haemorrhage  will  be  less  annoying. 

Preliminary  tracheotomy  and  plugging  the  pharynx  and  larynx  with 
sponges  in  order  to  prevent  heemorrhage  into  the  trachea  is  rarely,  if 
ever,  required.  If  such  precaution  is  considered  necessary,  an  ordinary 
trachea-tube  will  suffice.* 

For  simple  osteoma,  or  for  necrosis  of  the  upper  jaw,  this  bone  may 
be  removed  without  incision  in  the  cheek.  In  one  case  I  removed  the 
left  superior  maxilla,  except  the  orbital  plate  entering  from  within  the 
mouth.  In  necrosis,  when  the  sub-periosteal  operation  is  permissible,  the 
procedure  is  devoid  of  great  difficulty. 

Neurectomy. — Exsection  of  a  portion  of  the  second  division  of  the 
fifth  nerve  may  be  made  at  three  points — at  its  exit  from  the  infra-orbital 
canal,  within  the  canal,  or  at  the  foramen  rotundum.  In  this  last  opera- 
tion the  spheno-maxillary  ganglion  is  also  extirpated.  If  the  cause  of 
the  neuralgia  is  peripheral,  make  an  incision  about  one  inch  long,  par- 
allel with  and  half  an  inch  below  the  lower  margin  of  the  orbital  cavity. 

*  Trendelenburg's  trachea-tube  and  tarnpon  is  such  a  complicated  apparatus  that,  when 
possible,  it  should  be  dispensed  with.  It  is  more  to  be  commended  in  laryngectomy  than  in 
any  other  operation  about  the  mouth  or  pharynx.  The  mechanism  of  this  tube,  and  the 
method  of  using  it,  are  given  on  page  505. 


Fig.  499.— (After  Eoser.) 


474  A  TEXT-BOOK   ON   SURGERY. 

The  center  of  this  cut  shoiild  be  over  tlie  infra-orbital  foramen,  which 
is  just  half  way  l)etween  the  outer  and  inner  angle  of  the  orbit.  The 
nerve  may  be  exsected  here  or  stretched  by  pulling  on  the  central  end. 
It  may  be  reached  at  a  point  considerably  behind  this  by  trephining  the 
antrum.  Make  a  curved  incision,  beginning  about  half  an  inch  below 
the  inner  canthus,  passing  downward  to  the  level  of  the  end  of  the  nose, 
thence  upward  to  a  point  about  half  an  inch  below  the  outer  canthus. 
Dissect  this  flap  upward,  apply  the  trephine  so  that  its  upper  edge  will 
cut  just  below  the  foramen  and  enter  the  antrum.  The  nerve  runs  di- 
rectly backward,  and  may  be  followed  by  keeping  it  as  a  guide  and 
breaking  off  the  lower  shell  of  the  canal  as  far  back  as  the  posterior  wall 
of  the  antrum,  where  it  is  divided. 

The  operation  for  the  removal  of  Meckel's  ganglion  has  already  been 
given. 

The  Lower  Jaw. 

Ostitis  of  the  inferior  maxilla  is  of  frequent  occurrence. 

Yarious  forms  of  fibroma,  fibro-myxoma,  encysted  fibroma,  enchon- 
droma,  and,  in  rare  instances,  angioma,  have  been  observed  in  this  bone, 
but  of  new  formations  sarcoma  is  most  frequent.  Cystic  formations 
resulting  from  failure  of  normal  development  of  the  teeth  are  not  un- 
common. 

Ostitis  occurs  most  frequently  in  children.  It  may  be  an  expression 
of  a  dyscrasia,  or  an  accident  of  nutrition,  or  be  secondary  to  disease  of 
the  teeth,  or  the  inhalation  of  the  fumes  of  phosphorus.  While  this 
process  may  be  located  at  any  portion  of  the  jaw,  the  neighborhood  of 
the  angle  seems  to  be  most  frequentlj^  affected. 

The  symptoms  are  pain,  followed  by  swelling  of  the  jaw  and  contigu- 
ous soft  tissues,  ending  in  abscess,  which,  if  left  alone,  eventually  opens 
and  discharges. 

Treatment. — As  soon  as  the  character  of  the  disease  is  evident,  an 
incision  or  puncture  should  be  made  through  the  overlying  tissues  and 
periosteum,  in  order  to  give  free  exit  to  pus  and  loose  particles  of  bone. 
The  operation  for  removal  of  the  dead  bone  may  be  delayed  for  several 
weeks  until  exfoliation  has  taken  place.  Incision  should  always  be  made 
below  the  line  of  the  jaw  if  this  is  feasible,  so  that  the  resulting  scar 
will  be  less  apparent.  Usually  by  following  the  track  of  the  abscess  it 
will  lead  directly  to  the  dead  bone  surrounded  by  an  involucrum.  This 
often  requires  to  be  chiseled  or  forced  open  to  allow  the  extraction  of 
the  sequestrum,  which  may  be  readily  removed  with  ordinary  bone-  or 
dressing-forceps.  The  cavity  should  be  weU  scraped  with  a  Yolkmann's 
spoon,  a  drainage-tube  left  in,  and  the  edges  of  the  wound  adjusted  with 
silk  sutures.  The  deformity  due  to  the  rich  deposit  of  callus  disappears 
with  the  absorption  of  this  material.  When  all  or  any  portion  of  the 
entire  thickness  of  the  Jaw  requires  removal  for  ostitis,  the  sub-perios- 
teal  operation  is  imperative,  since  by  this  means  alone  is  it  possible  to 
have  a  reproduction  of  the  bone.     The  method  of  procedure,  when  the 


THE   LOWER   JAW. 


475 


bone  is  the  seat  of  a  neoplasm,  depends  upon  the  character  of  the  new 
formation.  If  there  is  any  doubt  as  to  the  benign  character  of  the  tumor, 
a  piece  should  be  removed  and  examined  microscopically  before  operation. 

In  sarcoma,  cancer,  and  enchondroma  of  the  jaw,  the  snb-periosteal 
operation  can  not  be  performed,  since  the  sound  tissues  must  be  included 
in  the  ablation,  in  order  to  secure  immunity  from  recurrence.  Enchon- 
droma, though  not  intrinsically  malignant,  tends  to  recur  if  not  freely 
excised. 

Operation. — AVhen  it  is  safe  and  possible,  the  diseased  portion  of  the 
lower  jaw  should  be  removed  without  breaking  the  continuity  of  the 
bone.  If  a  portion  of  the  entire  thickness  of  the  organ  is  removed,  the 
tendency  to  displacement  is  inward,  thereby  interfering  with  mastica- 
tion. The  entire  thickness  of  the  jaw  should  be  included  in  exsection 
for  malignant  neoplasm. 

Partial  resection  of  the  upper  or  alveolar  portion  of  the  body  of  the 
lower  jaw  in  front  may  be  accomplished,  in  mild  cases,  from  within  the 
buccal  cavity.  When  the  disease  is  extensive,  proceed  as  follows  :  At  a 
distance  from  the  alveolar  margin  sufficient  to  permit  the  exposure  of 
all  diseased  bone  make  an  incision  parallel  with  the  margin  of  the  li^^, 
and  also  parallel  with  the  inferior  border  of  the  jaw.  This  incision  should 
extend  in  depth  to  the  bone  and  in  length  beyond  the  area  of  disease. 
The  bone  is  next  divided  by  the  chisel  and  mallet,  the  key-hole  saw,  or 
removed  in  small  pieces  by  the  ron- 
geur, in  the  line  indicated  in  Pig. 
500.  The  operation  is  concluded 
by  bringing  the  Hap  back  into  place 
with  silk  sutures. 

When  the  disease  is  more  gen- 
eral, necessitating  a  removal  of  the 


Fig.  500. — Line  of  section  in  removinfr  tte  alveo- 
lus' of  the  lower  jaw.     (After  Eoser.) 

entire   thickness   of   the    bone,    a 

more  extensive  incision  is  required. 

The  lip  is  divided  in  the  median 

line  down  to  the  under  surface  of 

the    chin,    and    thence   along  the 

lower  border  of  the  jaw  (Fig.  501). 

When    the    ramus    and    ai'ticular 

process  require  removal,  the  line  of  incision  may  be  carried  to  the  angle 

and  up  the  ramus.     In  disarticulation,  while  the  incision  through  the 

skin  can  be  safely  carried  as  high  as  the  zygoma,   the  incision  down 

to  the  bone  should  not  extend  farther  than  on  a  level  with  the  tip  of 


Fio.  501.— (After  Eoser.) 


476  A  TEXT-BOOK   ON  SURGERY. 

the  mastoid  process,  for  fear  of  dividing  the  facial  nerve.  From  this 
point  the  coracoid  process  and  tlie  articulation  may  be  reached  by  work- 
ing lip  close  to  the  surface  of  the  bone,  beneath  the  periosteum  (if  the 
disease  is  not  malignant).  The  inferior  dental  artery  should  be  secured 
when  divided,  and  the  other  branches  of  the  internal  maxillary  avoid- 
ed. The  external  carotid  is  left  behind  the  ramus.  In  the  act  of  dis- 
articulation it  must  be  remembered  that  the  internal  carotid  artery  and 
internal  jugular  vein  enter  the  cranium  just  behind  the  vaginal  process 
of  the  temporal  bone,  which  forms  the  posterior  wall  of  the  articula- 
tion. As  this  process  is  only  about  one  eighth  of  an  inch  thick,  the  walls 
of  the  vein  and  artery  are  in  dangerous  proximity  to  the  attachment  of 
the  capsule.  The  anterior  and  outer  wall  of  the  capsule  should  be  first 
separated,  and  then,  while  strong  outward  traction  is  made  on  the  ramus, 
the  inner  wall  of  the  cajjsule  should  be  divided  as  close  to  the  neck  of 
the  bone  as  possible.  If  ablation  of  the  entire  bone  is  demanded,  this 
operation  is  repeated  for  the  opposite  side.  It  must  not  be  forgotten  that 
when  the  attachments  of  the  hyoid  muscles  to  the  jaw  are  severed,  the 
action  of  the  remaining  muscles,  together  with  gravity,  aid  in  carrying 
the  base  of  the  tongue  backward  upon  the  glottis,  producing  dangerous 
if  not  fatal  asphyxia.  The  precaution  of  passing  a  thread  through  the 
tip  of  the  tongue  should  not  be  overlooked. 

Resection  of  the  inferior  dental  nerve  may  be  performed  at  the  men- 
tal foramen,  or  at  the  commencement  of  the  dental  canal  at  the  angle 
of  the  jaw. 

The  mental  foramen  is  situated  about  half  way  between  the  inferior 
border  of  the  bone  and  the  alveolar  border  or  necks  of  the  teeth.  A 
line  let  fall  perpendicularly  from  the  interspace  between  the  two  bicuspid 
teeth  of  the  lower  jaw  will  pass  over  the  opening.  A  curved  or  crucial 
incision  will  expose  the  nerve  at  this  point. 

The  foramen  of  entrance  of  the  inferior  dental  nerve  is  very  near  the 
center  of  the  quadrilateral  formed  by  the  anterior  and  posterior  margins 
of  the  ramus,  the  lower  horizontal  border  of  the  angle,  and  an  imaginary 
horizontal  line  on  a  level  with  the  lowest  portion  of  the  sigmoid  notch. 

An  incision  about  two  inches  long  and  slightly  curved  is  made  so 
that  its  middle  will  be  about  the  center  of  the  parallelogram  above  de- 
scribed. The  trephine  should  be  applied  over  the  center  of  the  quadri- 
lateral. The  best  indication  of  having  reached  the  nerve  is  the  bleeding 
through  the  track  of  the  trephine  when  it  passes  into  the  cancellous  tis- 
sue of  the  jaw.  This  comes  from  the  wounded  inferior  dental  vessels. 
An  elevator  placed  in  the  cut  wUl  now  lift  the  button  of  bone,  and  the 
nerve  is  exposed.  The  entire  portion  in  the  limit  of  the  trephine  should 
be  excised.  Temporary  relief  is  almost  invariably  secured,  although  a 
recurrence  of  pain  is  not  uncommon  after  several  months. 

■Anchylosis. — Motion  of  the  jaw  may  be  limited  or  entirely  prevented 
by  muscular  rigidity,  cicatricial  contractions,  or  true  anchylosis  at  the 
temporo-maxillary  articulation. 

The  area  of  motion  in  partial  anchylosis  may  be  increased  by  forcible 
separation  of  the  lower  from  the  upper  jaw  by  the  apparatus  shown  in 


THE    LOWER   JAW. 


477 


Fig.  37.  This  should  be  repeated  at  frequent  intervals,  gradually  in- 
creasing the  pressure.  In  severe  cases  a  false  joint  may  be  successfully 
established  by  section  of  the  bone  anterior  to  the  point  of  fixation,  usual- 
ly at  or  above  the  angle.  Care  must  be  taken  to  make  frequent  pas- 
sive motion  in  order  to  prevent  union  of  the  divided  ends. 


Flo.  503. — Incisor,  half-curved  root. 


The  Teeth. 

Extraction. — Dental  forceps  should  be  of  different  patterns,  the  jaws 
bent  at  various  angles  to  the  shaft,  and  the  handles  large  enough  to  be 
grasped  firmly  and  securely  by  the  operator. 

The  gum  immediately  around  the  neck  of  the  tooth  should  be  free- 
ly incised  with  a  lancet,  since  If  this  precaution  is  not  taken  it  may 

be  unnecessarily  torn 
away  with  the  tooth. 
The  injection  of  cocaine 
around  the  tooth  will 
render  the  cutting  pain- 
less. The  jaws  of  the 
forceps  are  applied  on 
either  side  of  the  neck, 
and  forced  down  to- 
ward the  root  until  they 
grasp  the  tooth  firmly 
at  the  margin  of  its 
alveolar  insertion.  The 
direction  of  traction  is  determined  by  the  normal  direction  of  the 
axis  of  the  tooth.  In  extracting  the  incisors  and  canine  teeth,  the  for- 
ceps represented  in  Figs.  .502  and  503  are  applied  as  described  above, 
and,  when  firmlyfixed, 
a  slight  forward  and 
backward  movement, 
with  limited  rotation, 
will  loosen  the  root, 
while  traction  should 
at  the  same  time  be 
made  in  a  direction 
upward  and  slightly 
forward  for  the  low- 
er jaw,  and  downward 
for  the  teeth  of  the 
upper  row.  For  the 
bicuspids  and  molars, 
the  instruments  shown 
in  Figs.  504,  505,  and 
606  are  preferable. 

The  bicuspids  and  molars  may  be  loosened  by  lateral  motion  or  rock- 


fiG.  504. — Wolvertor's  upper  bicuspids. 


Fig.  505.— Wolverton's  lower  bicuspids. 


47S 


A  TEXT-BOOK   ON  SURGERY. 


ing.  The  direction  of  traction  is  slightly  inward  for  the  lower  teeth,  and 
slightly  outward  for  those  of  the  upper  jaw. 

Fracture  of  a  root  or  shelving  of  the  alveolus  will  occur  at  times 
in  the  most  skillful 
hands,  and  abscess 
and  necrosis  may  en- 
sue. Fragments  of 
the  teeth  should  be 
gouged  out  by  using 
an  elevator.  Haemor- 
rhage, usually  iusig- 
nilicant,  may  at  times 
be  dangerous,  death 
having  occurred  from 
this  cause  in  one  or 
more  instances.    Cold 

or  heat,  or  packing  the  cavity  with  a  compress  of  cotton  or  lint,  will 
effect  its  arrest.  In  extreme  cases  the  compress  may  be  saturated  with 
Monsel's  solution,  or  alum,  or  any  astringent,  and  left  in  for  forty-eight 
hours.  Anaesthetics  may  be  employed  ^vith  great  safety  in  dental  surgery. 
Nitrous  oxide  is  of  every-day  use,  and  ether  is  both  safe  and  effective. 
Chloroform  is  not  to  be  employed  unless,  after  full  information,  the  pa- 
tient relieves  the  operator  of  all  responsibility.  "When  ether  or  chloro- 
form are  administered,  the  patient  should  be  placed  in  the  recumbent 
posture. 


Fig.  506. — Harris's  lo'n-er  molars,  lor  the  two  sides. 


The  Palate. 

Uvula. — On  account  of  elongation  or  hypertrophy  of  this  portion  of 
the  soft  palate,  its  excision  is  at  times  required.-  It  may  be  accomplished 
by  taking  hold  of  the  tip  with  a  mouse-tooth  forceps,  and  with  a  long 
curved  scissors  removing  as  much  as  required.  Complete  local  anaesthe- 
sia may  be  obtained  by  mopping  the  uvula  with  a  small  quantity  of  a 
4-per-cent  solution  of  cocaine  hydrochlorate  at  intervals  of  three  min- 
utes for  fifteen  minutes  before  the  operation. 

Tumors  of  the  palate,  abscess,  necrosis,  and  ulceration  are  not  infre- 
quent, and  demand  the  same  treatment  as  in  other  portions  of  the  body. 

Cleft  palate  may  be  confined  to  the  soft  palate  ;  it  may  include  with 
this  a  portion  or  all  of  the  hard  palate  and  alveolus,  or  it  may  be  con- 
fined to  the  hard  palate  alone.  It  is  usually  congenital,  although  it 
may  be  acquired,  as  in  the  perforations  which  ensue  as  a  result  of  syphi- 
litic ulceration  and  necrosis. 

The  cleft  in  the  hard  palate  is  most  often  single,  the  vomer  being 
attached  to  one  side  of  the  palate-process  of  the  superior  maxilla  (Fig. 
460V  Occasionally  it  is  double,  there  being  a  central  piece — the  vomer — 
which  runs  forward  and  is  attached  to  the  pre-maxillary  bone  (Fig.  461). 

Treatment. — When  a  hare-lip  exists  as  a  complication  of  cleft  palate, 
the  operation  on  the  lip  should  first  be  made  in  order  to  enable  the  child 


THE   PALATE. 


•470 


to  swallow  sufficient  iiourishiTient,  and  to  gain  the  additional  ndvanlnge  of 
pressure  ol"  the  united  lij),  wliich  aids  in  approximation  of  the  (xlges  of 
the  cleft  in  tlie  hard  palate. 

The  most  suitable  nge  feu*  operatiiii;'  is  wilhin  Ihe  lirst  tlir(>e  ye;u's  of 
life,  if  the  infant  is  suificiently  sti'ong  and  well  noiirislunl  to  endure  so 
formidable  a  procedure.  One  of  the  most  discotiraging  features  of  this 
operation,  if  postponed  until  later,  is  that,  owing  to  the  shorleniiig  jiiid 
failure  of  development  in  the  ])alate  mu.scles,  it  is  ]n'a('lica]ly  imjtossihlf 
to  acquire  a,  natural  ai'ticulaliou,  ev(>n  nl'ler  llie  lissure  has  been  suci^ess- 
fully  closed. 

When  the  cleft  is  general — that  is,  entirely  through  the  .sol't  and  hard 
palate — it  is  advisable  to  close  the  soft  jiortion  lirst  and  linisli  the  re- 
mainder in  one  or  more  sittings,  as  niiiy  be  found  ne(v>ssary.  In  chil- 
dren, chloroform  should  be  uschI  ;  in  ndult.s,  a  su(lici(>nt  degree  of  local 
amBsthesia  may  be  obtained  by  the  employment  of  hydrochlorate  of  co- 
caine to  enable  the  operation  to  be  done  with  the  very  vabud)le  aid  of 
the  patient. 

In  a  case  oy)erated  upon  by  myself,  the  ]Ki,rts  to  be  incised  wci'e 
brushed  over  with  a  4-per-cent  solution  of  cocaine  :i,t  intei'vnls  of  two  or 
three  minutes  for  half  an  hour  pre(!eding,  :uid  about  (n'ery  live  minules 
during,  the  oj)e)'ation.  The  anjcsthesia,  was  perbiclly  satisfactory,  and 
complete  union  resulted  after  the  lii'st  operation. 

Operation  of  Slapliylorrajiliii. — The  lii-st  object  in  this  opc^ratioii  is 
to  keep  the  mouth  of  the  patient  widely  oj)ened.  For  tliis  put  pose 
Goodwillie's  gag  is  the  best  of  :dl  iiisti-umeiUs  (l'"'igs.  'Xi  and  \\('i).     The 

tongue  may  be  d('i)r(\ssed 
with  ;i  spniida.  if  neces- 
sary. If  ;iH  ;i,ua'stlietic  is 
eiu])loyed,  the  condition  of 
n!ir(!osis  should  not  beyiro- 
found,  foi',  if  laryng<sil  sen- 
sil>ility  is  complet('ly  lost, 
blood  or  mucus  may  jjuss 
iuto  thelnryuxjuid  (rachen, 
inslcjul  of  being  swnllowcid. 
'i'iie  i)atient's  head  being 
lirndy  luild  by  an  assistant, 
the  soft  i)nlate  is  seized 
by  a  mouse- tooth  iixntion- 
forceps,  and  willi  ii.  blinit- 
pointed,  long  nai'iow  knife 
(Fig.  CO)  a  strip,  a])Out  one 
eighth  to  one  sixteenth  of 
an  inch  wide,  is  i-emoved 
from  the  edges  of  the  fis- 
sure, in  its  entire  length 
(Fig.  n07).  In  order  to  steady  the  palate,  a  silk  threnxl  may  be  inserted 
on  either  angle,  or  a  ,s(!cond  forceps  applied,  although  this  is  not  always 


sift' 


Fio.  507.— Freftlieninc  tho  mnrgin  of  tho  oloft  in  tliu  (i])(!niti 
of  utttphyloiTapliy.     (A'tor  Mulguigiui.) 


480  A  TEXT-BOOK   ON  SURGERY. 

necessary.  The  entire  margin  of  tlie  cleft  must  be  carefully  freshened, 
for  if  any  point  is  left  uncut  union  wiU  fail.  The  bleeding  is  next 
arrested  by  small  sponges,  on  staffs  (Fig.  83),  dipped  in  ice-water  and 
squeezed  dry. 

In  uniting  the  freshened  edges,  Dr.  Goodwillie's  hollow  needle  (Fig. 


Fig.  508. — Goodwillie's  hollow  needle  for  silk-worm  gut  suture  in  the  closure  of  cleft  palate. 

508)  is  the  best  instrument,  while  the  silk- worm  gut  siiture  leaves  noth- 
ing to  be  desired  in  this  operation. 

To  the  shaft  adjust  one  of  the  needles  which,  from  its  shape,  is  best 
adapted  to  the  peculiar  form  of  the  fissure  to  be  closed,  and  push  one  of 
the  silk- worm  bristles  through  from  the  butt  to  the  point  until  it  projects, 
and  then  draw  it  back  one  eighth  of  an  inch  within  the  eye  of  the  needle. 
Seize  the  edge  of  the  flap  with  the  forceps,  and  at  a  point  between  one 
eighth  and  one  fourth  of  an  inch  from  the  freshened  margin  of  the  fissure 
insert  the  needle  from  before  backward,  through  the  side  corresponding 
to  the  operator's  right  hand  (left  side  of  the  patient),  and  then  through 
the  opposite  side,  at  a  like  point  from  behind  forward.  In  order  to 
facilitate  the  passage  of  the  needle,  the  flap  must  be  held  steadily  with 
the  forceps.  As  soon  as  the  needle  has  transfixed  the  second  flap  and 
the  eye  is  visible,  the  operator  pushes  on  the  bristle  at  the  butt  of  the 
needle-holder,  causing  the  other  end  to  come  out  of  the  eye  of  the  needle, 
when  it  is  seized  with  the  forceps  and  drawn  forward.  Holding  this  end 
firmly,  the  needle  is  withdrawn,  leaving  the  suture  in  position.  The  ends 
of  this  are  now  fastened  together  with  a  perforated  shot,  and  held  aside 
until  all  are  inserted.  The  sutures  should  be  about  one  fourth  of  an  inch 
apart.  When  the  last  one  is  inserted,  the  operator  ties  one  after  another 
from  above  downward.  The  first  knot  is  single,  and  this  is  run  down 
tight  and  repeated  with  two  additional  knots  to  secure  it.  The  ends  are 
then  cut  off,  one  fourth  of  an  inch  from  the  knot.  This  material  ties 
easily,  does  not  slip  or  break,  is  not  absorbable,  and  holds  its  place  until 
removed. 

After  the  sutures  are  tied  it  will  be  observed  that  (as  a  result  of  the 
fissure,  the  levator  palati  and  palato-pharyngeus  muscles  being  shortened) 
there  is  now  marked  tension  of  the  soft  palate,  which,  if  not  relieved, 
will  pull  upon  the  sutures  and  cause  separation  of  the  edges  of  the 
wound.  To  obviate  this,  a  sharp  knife  (Fig.  55)  is  thrust  through  the' 
palate,  about  the  center  of  the  posterior  margin  of  the  horizontal  plate 
of  the  palate-bone  of  that  side,  and  an  incision  made,  in  a  direction 
downward  and  outward,  to  within  from  one  fourth  to  one  half  of  an 
inch  from  the  free  border  of  the  palate,  near  the  hamular  process,  as  in 


d 


THE   PALATE. 


481 


Fig.  509.  This  incision  divides  the  levator  palati  of  either  side.  The 
anterior  and  posterior  pillars  of  the  fauces  should  also  be  snipped  with 
dull-pointed  scissors.  All  of  these  wounds  close  later  by  granulation. 
It  is  important  to  keep  the  muscles  of  this  region  at  rest  for  a  week  after 
the  operation. 

When  the  cleft  extends  into  the  hard  palate,  as  shown  in  Fig.  510, 
the  fissure  may  be  closed  by  sliding  the  membrane  lining  the  vault  of  the 
palate. 


Fig.  509.— (After  Agnew.) 


Fig.  510. — Incisions  in  sliding  tlie  periosteum  for  clos- 
ure of  the  bony  cleft.    (Modified  from  Koenig.) 


The  edges  of  the  fissured  soft  palate  are  freshened,  as  in  the  preceding 
operation.  Along  the  edges  of  the  bony  fissure  an  incision  {a  b,  Fig.  510) 
is  made,  with  a  knife  shaj)ed  like  a  gum-lancet  (Fig.  57),  and,  by  the  aid 
of  curved  elevators  (Fig.  71),  the  membrane  lining  the  bony  palate  is 
carefully  lifted  with  the  periosteum.  Another  incision  is  now  made  on 
either  side  of  the  fissure,  close  to  and  parallel  with  the  junction  of  the 
alveolus  with  the  palate  processes,  A  B,  through  which  the  elevator  is 
again  introduced,  and  the  periosteum  lifted  until  the  whole  flap  included 
between  B  A  and  the  edges  of  the  fissure  a  b  is  detached.  If  severe 
haemorrhage  follows  the  incision,  the  wound  should  be  temporarily 
packed  with  lint,  or  pressure  with  the  finger  may  arrest  the  bleeding. 

The  flaps  are  now  ready  for  sliding,  and  the  sutures  are  introduced 
along  the  freshened  edges,  as  in  the  preceding  operation. 

When  the  cleft  extends  still  farther  forward  through  the  alveolus, 
and  the  fissure  is  wide,  it  will  become  necessary  to  carry  the  palate  pro- 
cesses toward  the  median  line  by  an  osteoplastic  operation.  In  this 
procedure  no  efl'ort  is  made  at  lifting  the  periosteum,  and  it  is  better  to 
attempt  the  approximation  of  only  one  portion  of  the  cleft  at  a  sitting. 
In  order  to  secure  all  the  nutrition  possible,  the  soft  palate  should  be 

31 


482 


A  TEXT-BOOK   ON  SURGERY. 


first  united.  The  anterior  or  posterior  j)ortion  of  the  bony  fissure  may 
be  closed  at  the  next  operation,  as  follows  :  Freshen  the  edges  of  the  soft 
jDarts  along  the  fissure.  Drill  two  holes  through  the  bony  palate  of  either 
side,  one  fourth  of  an  inch  distant  from  the  edges  to  be  approximated, 
and  insert  two  strong  silver  wires,  as  shown  in  Fig.  511.  On  either  side, 
close  to  and  parallel  with  the  alveolus,  make  two  incisions  through  to 
the  bone,  as  at  A  B  (Fig.  510),  and  drill  with  an  awl  a  series  of  holes  in 
the  track  of  these  incisions.  A  few  strokes  of 
a  small  chisel  will  now  break  the  palate  pro- 
cesses in  the  line  of  the  holes,  when,  by  twist- 
ing the  wires,  the  loosened  plates  will  be  ap- 
proximated in  the  median  line.  After  union 
has  occurred  in  this  portion  of  the  cleft,  the 
operation  may  be  com^sleted  in  the  anterior  por- 
tion, by  drilling  the  palate  and  alveolus,  and 
breaking  this  last  through  from  the  front  with 
a  chisel,  approximating  the  sides  as  above. 

Perforations  of  the  palate  are  treated  prac- 
tically in  the  same  way  as  congenital  cleft,  by 
freshening  the  edges,  and,  if  necessary,  sliding 
the  periosteum,  as  -above  given. 


Fig.  511. — (After  Agnew.) 


The  Tongue  and  Buccal  Cavity. 

Wounds  of  the  tongue  bleed  profusely,  especially  if  the  larger  vessels 
along  its  under  surface  are  divided.  The  arrest  of  haemorrhage  is  easily 
and  safely  accomplished  by  introdiacing  the  index-finger  well  back  over 
the  dorsum  to  the  root  of  the  tongue,  and  bringing  the  organ  well  for- 
ward and  forcibly  compressing  it  against  the  symphysis  menti.  The  tip 
of  the  organ  should  be  turned  upward,  and  the  forceps  applied  at  the 
bleeding  points.  In  the  substance  of  the  tongue  the  vessels  are  also 
readily  secured  in  the  same  manner.  Should  any  difficulty  arise,  a  silk 
thread  may  be  carried  around  the  bleeding  vessel  by  means  of  a  curved 
needle,  or  it  may  be  transfixed  with  a  tenaculum  and  the  thread  tied 
around  the  hook. 

Glossitis — Hemi glossitis. — Inflammation  of  the  tongue  may  result 
from  the  same  causes  and  assume  all  the  phases  of  inflammation  common 
to  the  soft  tissues  in  other  portions  of  the  body.  It  may  be  acute  or 
chronic,  ending  in  ulceration  or  hypertrophy.  The  process  may  begin 
suj)erficially,  as  after  the  ingestion  of  some  irritating  substance,  or  it 
may  commence  in  the  deeper  portions  of  the  organ  as  a  diffuse  phleg- 
monous process.  In  some  instances  only  one  lateral  half  of  the  organ 
is  involved. 

Treatment. — Inflammation  of  the  tongue  from  any  cause  should  be 
closely  watched,  on  account  of  the  danger  of  asphyxia  from  rapid  en- 
largement of  this  organ.  In  this  emergency  tracheotomy  should  be 
performed.     If  abscess  forms,  incision  or  puncture  is  demanded.    Scarifi- 


THE   TO^'GUE   AXD   BUCCAL   CAVITY.  483 

cation  may  be  required  in  rapid  enlargement  of  this  organ  from  engorge- 
ment of  the  vessels. 

HypertropTiy  of  the  tongue  is  both  congenital  and  acquired.  It  may 
exist  in  adult  Ufe,  although  it  is  in  general  a  condition  of  childhood. 
The  enlargement  is  due  to  hypertrophy  of  the  lymphatic  plexuses  of 
this  organ  and  to  a  genei-al  hyperplasia  of  the  connective -tissue  elements. 
The  muscular  substance  undergoes  granular  metamorphosis.  The  cause 
of  this  disease  is  not  understood.  The  organ  may  become  so  large  that 
it  protrudes  fi'om  the  mouth,  pushes  the  teeth  out  of  their  normal  po- 
sition, and  interferes  with  deglutition  and  respiration  to  such  an  extent 
that  its  partial  or  complete  removal  becomes  necessary.  Cystic  tumors 
of  the  tongue  may  be  mistaken  for  hypertrophy.  A  diag-nosis  may  be 
made  by  exploration  \\-ith  a  good-sized  aspirator-needle. 

In  mild  cases  deligation  of  the  lingual  artery  of  one  or  both  sides 
may  be  done,  and  this  may  be  followed  by  excision  of  a  portion  of  the 
organ.  The  tip  may  be  amputated,  or  a  triangular  section  may  be  re- 
moved from  the  central  portion,  the  sides  being  brought  together  by 
sutures. 

Atrophy  is  a  rare  disease,  and  is  due  to  diminution  of  the  blood- 
supply,  or  to  lesions  of  the  trophic  nerves  of  this  organ. 

Cystic  tumors  of  the  tongue  may  be  caused  by  closure  of  the  outlet 
to  any  portion  of  the  follicular  apparatus  (retention-cysts),  or  less  fre- 
quently by  the  lodgment  in  this  organ  of  a  parasite,  the  cysticercus. 

The  diagnosis  is  made  positive  by  exploration.  The  treatment  re- 
quired is  excision  of  the  sac  -nith  the  scissors,  or  the  less  bloody  oper- 
ation of  opening  it  with  the  Paquelin  cautery,  burning  the  lining  mem- 
brane thoroughly,  and  packing  the  cavity  with  iodoformized  gauze. 
The  precaution  should  be  taken  to  make  the  packing  from  one  piece  of 
gauze,  and  of  securing  it  by  a  thread  attached  outside,  in  order  to  pre- 
vent its  accidental  escape  backward. 

Angioma  of  the  tongue  is  rare.  AVhen  present,  the  treatment  is  re- 
moval by  the  ligature,  or  by  injection  with  oO-per-cent  carbolic-acid 
solution. 

Abscess  of  the  tongue  should  be  treated  by  aspiration,  and  hyper- 
distention  of  the  sac  with  l-to-3000  sublimate  solution.  If  this  does  not 
succeed,,  an  incision  should  be  made  and  drainage  secured. 

Ulcers  of  the  tongue  appear  as  a  symptom  of  various  conditions. 
They  occur  in  syphilis  with  great  fi-equency.  They  may  occur  as  a 
result  of  general  catarrh  of  the  pharynx  and  mouth,  or  as  a  result  of  any 
violence.  If  an  ulcer  exists  as  an  expression  of  a  dyscrasia,  the  treat- 
ment must  be  chiefly  constitutional.  The  local  treatment  consists  in 
cleanliness  and  the  application  of  nitrate  of  silver,  or  other  stimulating 
remedies. 

The  tongue  is  at  times  the  seat  of  papilloma,  lipoma,  Jibroma,  sar- 
coma, and  one  or  two  instances  of  enchondroma  in  this  organ  are  re- 
ported. Epithelioma  is  not  infrequent,  and  is  the  most  important  of 
the  neoplasms  of  this  organ,  not  only  on  account  of  its  greater  frequency, 
but  also  on  account  of  its  grave  character  and  the  necessity  of  arriving 


484  A  TEXT-BOOK  ON  SUEGERY. 

at  an  early  diagnosis  of  the  disease.  The  late  manifestations  of  syphilis 
(nlcers,  gumma,  fissures),  ulcers  of  tuberculosis,  and  some  specific  ulcers, 
and  papilloma,  may  be  mistaken  for  this  neoplasm. 

If  a  patient  has  a  syphilitic  history,  gumma  or  specific  iilcer  will 
naturally  be  suspected.  If  large  doses  of  potassium  iodide  be  adminis- 
tered for  two  or  three  weeks,  the  specific  ulcer  will  respond  to  this  rem- 
edy. If  no  impression  is  made  upon  it,  it  should  be  treated  as  ma- 
lignant. As  regards  all  other  suspicious  sores  of  this  organ,  it  will  be 
the  wiser  practice  to  treat  them  also  as  malignant  growths,  for  it  is  a 
well-recognized  fact  that  papillomatous,  tuberculous,  and  simple  ulcers 
of  the  tongue  (as  elsewhere),  chronic  in  character,  are  capable  of  trans- 
formation into  epithelioma.  If  these  sores  are  removed  early  in  their 
history,  no  mutilation  is  required,  the  operation  is  without  danger,  only 
a  small  portion  of  the  organ  need  be  sacrificed,  and  the  focus  of  dis- 
ease is  removed  before  its  malignant  nature  is  declared  or  metastasis 
occurs.  If  an  epitheliomatous  ulcer  exists,  its  character  may  be  deter- 
mined by  microscopical  examination,  as  given  by  Biitlin.*  If  the  scrap- 
ing from  a  tuberculous,  syphilitic,  or  simple  ulcer  is  placed  in  a  drop  of 
water  on  a  slide,  pus-  and  blood- corpuscles,  particles  of  food,  bacteria, 
and  a  few  normal  or  almost  normal  epithelial  cells,  are  observed.  If 
the  scraping  from,  an  ej)itheliomatous  ulcer  be  examined,  in  addition  to 
the  above  will  be  seen  a  great  number  of  abnormal  epithelia,  varying  in 
size  and  shape,  some  flattened  scales,  others  round  or  oval,  others  elon- 
gated, with  caudate  prolongations.  The  cells  are  generally  granular,  and 
possess  from  two  to  three  or  more  nuclei,  much  larger  than  the  normal 
nuclei  of  these  cells.  In  some  instances  the  "  swallow's-nest "  arrange- 
ment may  be  observed. 

If  no  ulcer  is  present,  a  section  for  microscopical  examination  may  be 
removed  from  the  indurated  mass. 

Operation. — The  method  of  procedure  must  be  determined  by  the 
extent  of  the  organ  to  be  removed.  If  the  induration  is  confined  to  the 
tip,  and  does  not  extend  more  than  one  inch  behind  this  point,  the  line 
of  section  should  be  at  or  near  the  center  of  the  tongue.  It  should  al- 
ways be  well  away  from  the  disease.  An  inch  from  the  nearest  indura- 
tion will  be  safer  than  to  allow  the  line  of  section  to  approach  the  neo- 
plasm in  order  to  save  more  of  the  tongue.  When  the  lateral  aspect  of 
the  anterior  half  is  involved,  the  line  of  section  need  not  pass  at  right 
angles  to  the  axis  of  the  organ,  but  may  curve  around  parallel  with  the 
limit  of  induration  at  a  sufficient  distance  from  it.  In  this  way  the  an- 
terior portion  of  the  oi^posite  half  may  be,  in  part,  preserved.  If  the 
floor  of  the  mouth  is  infiltrated,  it  should  be  dissected  from  its  attach- 
ments to  the  jaw,  and  the  diseased  part  removed  with  the  tongue.  If 
the  disease  extends  to  the  middle  of  the  tongue,  and  involves  its  entire 
width,  the  organ  should  be  removed  at  its  base,  and  the  floor  of  the 
mouth  thoroughly  cleared  of  all  suspicious  tissue.-  The  lymphatics  in 
the  middle  line  below  the  symphysis  menti,  in  the  submaxillary  region 

*  "  Diseases  of  the  Tongue,"  Lea  Brothers  &  Co.,  Philadelphia,  1885. 


THE   TOXGUE   AXD   BUCCAL   CAVITY.  485 

and  down  the  neck,  should  be  examined  and  removed  if  metastasis  has 
occurred. 

When  the  floor  of  the  mouth,  together  with  the  anterior  two  thirds 
of  the  organ,  are  involved,  and  metastasis  is  evident  in  the  deeper  lym- 
phatics, the  propriety  of  surgical  interference  is  questionable.  A  cure 
is  not  pi'obable,  and  the  operation  formidable  and  dangerous.  The  re- 
moval of  the  ulcerating  portion  may  be  done  as  a  palliative  measure. 

AYithout  regard  to  the  manner  in  which  the  operation  is  to  be  per- 
formed, the  ether  should  be  administered  at  first  through  the  mouth, 
and,  after  the  narcosis  is  complete,  when  it  becomes  necessary  to  work 
within  this  cavity,  the  anfesthesia  should  be  carefully  continued  by  the 
rectum.  It  is  essential  for  the  teeth  to  be  held  widely  separated  by  the 
gag  (Fig.  36),  and  the  lips  held  out  of  the  way  by  flat,  blunt  retractors. 

In  mild  cases,  where  the  disease  is  situated  near  the  tip  of  the  organ, 
and  where  the  floor  of  the  mouth  is  not  involved,  the  operation  may  be 
done  with  the  galvano-cautery  loop,  as  follows  :  The  tongue  should  be 
drawn  well  out  of  the  mouth  and  transfixed  from  its  under  surface  \\'ith 
a  strong  needle  (armed  with  a  heavy  silk  thread)  at  a  jDoint  in  the 
healthy  tissue  where  the  section  is  to  be  made.  One  end  of  the  wire  of 
a  galvano-cautery  battery  is  fastened  to  the  thread,  drawn  thi'ough  the 
tongue,  attached  to  the  ecraseur  apparatus,  and  the  loop  tightened  so 
as  to  grasp  the  organ  in  the  direction  it  is  desii-ed  to  make  the  section. 
"VVTien  it  is  not  divided  entirely  across,  the  antero-posterior  section  is 
first  made.  The  wire  is  now  slowly  heated  to  a  red  color,  and  the  loop 
is  very  slowly  tightened  and  drawn  through  the  organ.  If  it  is  made  to 
cut  through  quickly,  the  vessels  may  not  be  occluded.  The  transverse 
section  is  next  made  in  the  same  way,  and,  if  any  attachments  to  the 
floor  of  the  mouth  remain,  these  may  also  be  divided  by  thro\ving  the 
loop  around  them. 

If  the  cautery  battery  is  not  at  hand,  the  Paquelin  thermo-cautery 
may  be  employed. 

If  neither  of  these  more  modern  instruments  are  to  be  had,  the  ecra- 
seur will  suffice.  It  is  not  only  efficient,  but  is  less  apt  to  get  out  of 
order  than  the  other  apparatus.  When  the  lingual  arteries  have  not 
been  tied,  haemorrhage  is  apt  to  occur  after  section  Avith  either  of  these 
instruments.  It  may  be  arrested  and  controlled  as  directed  in  wounds 
of  this  organ. 

When  a  more  extensive  operation  is  required,  the  following  method 
will  be  advisable  : 

A  careful  examination  of  the  lymphatic  glands  of  the  submaxillary 
and  cervical  regions  should  be  made,  and  if  any  induration  is  discovered 
they  should  be  removed  as  the  first  step  in  the  operation.  If  the  dis- 
ease has  existed  for  several  months,  in  all  probability  metastasis  has 
occurred,  even  when  the  enlargement  of  the  glands  can  not  be  detected 
by  palpation.  This  condition  is  especially  apt  to  exist  in  the  glands  cor- 
responding to  that  side  of  the  tongue  upon  v\-hich  the  disease  originated. 
It  is,  therefore,  a  wise  precaution  to  tie  the  lingual  artery  of  that  side, 
since  this  not  only  lessens  the  danger  of  hsemorrhage  in  the  removal  of 


486  A  TEXT-BOOK  ON   SURGERY. 

the  tongue,  but  exposes  the  glands  of  the  submaxillary  and  upper  cer- 
vical triangles,  and  facilitates  their  removal  if  involved.  The  operation 
of  tying  this  artery  has  been  given  on  page  246.  It  can  readily  be  secured 
opposite  the  central  tendon  of  the  digastric  muscle,  at  which  point  it 
is  almost  always  situated  half  way  between  the  insertion  of  this  tendon 
and  the  hypoglossal  nerve,  which  is  from  a  quarter  to  a  half  inch  above. 
In  two  instances  I  have  divided  the  posterior  belly  of  this  muscle  in  order 
to  expose  the  vessel  thoroughly.  When  this  is  accomplished,  the  wound 
should  be  irrigated  with  sublimate  (1  to  3000),  a  drainage-tube  inserted, 
and  the  sutures  applied. 

The  ether  should  at  this  stage  of  the  operation  be  transferred  to  the 
rectum,  the  gag  inserted,  and  the  lips  retracted. 

It  is  important,  in  dissecting  out  the  floor  of  the  mouth  and  the  tongue, 
to  be  able  to  control  all  hsemorrhage  and  at  the  same  time  to  fix  the  tongue. 
This  may  be  accomplished  in  a  most  satisfactory  manner,  and  may  be 
considered  as  the  second  step  in  this  operation.  An  incision  about  an 
inch  long  is  made  in  the  median  line,  commencing  at  the  hyoid  bone 
and  extending  toward  the  symphysis.  By  this  incision  the  integument 
and  deep  fascia  are  divided.  A  long  steel  needle,  with  the  eye  at  the 
point  (Peaslee's  instrument  will  suffice),  armed  with  a  strong  silk  thread, 
is  introduced  through  the  wound,  and,  while  the  tongue  is  drawn  well 
forward,  the  point  of  the  needle  is  pushed  along  the  inner  surface  of 
the  lower  jaw  into  the  mouth  by  the  side  of  the  tongue  at  its  base. 
One  end  of  the  thread  is  pulled  out  through  the  mouth,  the  needle 
withdrawn,  and  the  end  of  the  thread  projecting  from  the  mouth  is 
again  carried  through  the  eye  of  the  needle.  This  is  now  introduced  by 
the  side  of  the  base  of  the  tongue  exactly  opposite  the  point  at  which 
it  entered,  and  is  brought  out  at  the  wound  below  the  chin.  A  strong 
wire  is  fastened  to  one  end  of  the  thread  and  is  pulled  into  the  mouth 
and  around  the  base  of  the  tongue  by  withdrawing  the  silk.  The  wire 
should  now  be  fastened  to  an  ecraseur  and  tightened  just  enough  to  con- 
trol the  bleeding.  In  this  manner  all  the  vessels  going  to  the  tongue 
and  the  floor  of  the  mouth  are  surrounded  and  controlled. 

The  third  stage  of  the  procedure  is  the  removal  of  the  tongue  and 
the  tissues  which  form  the  floor  of  the  mouth.  In  doing  this  the  Paque- 
lin  cautery-knife  will  be  found  exceedingly  useful.  If  it  is  not  at  hand, 
the  scissors  or  knife  may  be  used.  A  strong  silk  thread  should  be 
passed  through  the  sound  tissues  of  the  tongue  near  the  end  and 
intrusted  to  an  assistant.  It  is  to  be  used  in  lifting  the  organ  as  the 
dissection  proceeds.  The  attachment  along  the  lower  jaw  should  first 
be  divided  and  the  tissues  dissected  up  until  the  tongue  can  be  lifted 
freely  to  a  point  at  least  one  inch  behind  the  induration.  The  ecraseur- 
loop  should  now  be  placed  around  the  organ  and  the  division  made  at 
the  desired  point.  If  at  this  time  the  wire  loop  which  is  around  the  base 
of  the  tongue  is  fairly  tight,  no  bleeding  will  occur  after  the  amputation. 
If  gradually  loosened,  the  bleeding  points  on  the  stump  can  be  readily 
seized  with  the  long-nosed  narrow  forceps  and  tied  with  silk  ligatures. 
In  the  after-treatment  no  dressing  is  applied  to  the  wound  in  the  mouth 


THE  TOXGUE  AND   BUCCAL   CA^^TY. 


48^ 


I  am  not  aware  that  tMs  method  of  controlling  hisemorrhage  in  this  oper- 
ation has  been  performed  by  any  other  surgeon. 

"When  the  inferior  maxilla  is  involved,  it  should  be  exsected  beyond 
the  limit  of  the  disease. 

If,  for  any  reason,  more  space  is  required  in  the  ablation  of  this 
organ  than  can  be  obtained  through  the  natural  orifice,  one  of  the  fol- 
lowing procedures  may  be 
adopted : 

1.  6^0  7'if5  incision  through 
the  cheek,  fi'om  the  angle  of 
the  mouth  in  the  direction  of 
the  lobe  of  the  ear  as  far  as 
required  (Fig.  513,  a).  This 
incision  gives  a  full  view 
of  the  lateral  aspect  of  the 
tongue,  and  may  be  made 
upon  both  sides  when  the 
disease  is  bilateral  and  ex- 
tends beyond  the  middle  of 
the  organ.  The  edges  of  the 
wound  are  afterward  brought 
together  by  hare-lip  pins  or 
silk  sutures. 

2.  Billroth  employs  a 
curved  incision  made  paral- 
lel with  the  arch  of  the  infe- 
rior maxilla  below  the  symphysis  (Fig.  512),  dividing  all  the  tissues  on 
this  line  until  the  floor  of  the  mouth  is  opened. 

3.  Koclier  has  lately  devised  an  operation  the  incision  in  which  is 
shown  by  the  line  h  d  e  c  (Fig.  513).  A  preliminary  tracheotomy  is  done, 
and  the  pharynx  stuffed  with  a 
carbolized  sponge  to  which  a  string 
is  attached.  The  excision  extends 
along  the  anterior  border  of  the 
sterno-mastoid  muscle,  from  the 
level  of  the  lobule  of  the  ear  to 
the  level  of  the  hyoid  bone,  along 
this  bone  to  near  the  median  line, 
and  thence  to  the  symphysis  menti. 
The  skin  and  platysma  are  turned 
up  on  the  jaw,  the  lingual  and  fa- 
cial arteries  and  veins  are  tied  as 
they  are  encountered,  all  enlarged 
glands  are  extirpated,  the  muscles 
and  floor  of  the  mouth  se^jarated 
along  the  attachments  to  the  lower 
jaw   to   anv  required   extent.     If  r.     ^i,    t    ■  ■      r  r^    ,     a  tt  -l 

'  -  i.  Fi5_  613.— Incision  of  Gant  and  Kocher. 

the  entire  tongue  is  to  be  removed,  (After  Butim.) 


Fig.  512.— Billroth's  incision.     (After  Butlin.) 


488  A  TEXT-BOOK  ON  SURGERY. 

the  opposite  lingual  is  also  tied.  Through  this  opening  the  tongue  is  drawn 
out,  dissected  from  its  anterior  and  lateral  attachments,  surrounded  with 
the  cautery-loop  and  divided,  or  cut  off  with  the  ecraseur  or  scissors. 

In  the  after-treatment  the  trachea-tube  is  left  in  place,  and  the  phar- 
ynx, mouth,  and  wound  filled  with  sponges  dipped  in  a  5-per-cent  car- 
bolic-acid solution,  the  excess  of  the  acid  being  washed  off  with  water 
before  the  sponges  are  applied.  The  wound  is  dressed  twice  a  day,  and 
liquid  nourishment  given  at  each  change  of  the  dressing. 

The  operation  of  Kocher  is  objectionable  on  account  of  the  extent  of  the 
dissection,  the  danger  of  submitting  such  a  large  wound  to  the  probabil- 
ity of  septic  infection  from  the  mouth,  and  the  complication  of  tracheot- 
omy. The  free  inspection  of  the  tissues  of  the  neck  which  it  permits,  and 
the  command  of  the  base  of  the  tongue  which  it  allows,  are  in  its  favor. 

The  operations  in  which  the  organ  is  removed  through  the  mouth  are 
simpler,  and  require  much  less  time  in  execution.  If  the  author's  method 
of  controlling  haemorrhage  is  adopted,  the  j^rocedure  is  practically  blood- 
less, and  a  preliminary  tracheotomy  is  unnecessary.  The  conditions 
which  call  for  the  operations  of  Gant,  Billroth,  or  Kocher  rarely  exist. 

The  after-treatment  consists  in  rinsing  the  mouth  at  frequent  inter- 
vals with  a  warm  solution  of  permanganate  of  potassa  (gr.  ss.  to  3]), 
anodynes  to  relieve  pain,  and  generous  liquid  diet. 

Ranula. — This  name  is  applied  to  certain  tumors,  cystic  in  character, 
which  are  situated  immediately  beneath  the  anterior  and  lateral  portions 
of  the  tongue.  Ranula  is  usually  acquired,  although  it  may  be  congeni- 
tal. The  tumor  is  almost  always  single ;  occasionally  there  is  one  on 
either  side  of  the  organ.  Commencing  as  a  result  of  obstruction  to  the 
outlet  of  one  of  the  subdivisions  of  the  sublingual  gland  (rarely  as  a 
result  of  occlusion  to  one  of  the  terminal  ducts),  it  may  grow,  when  left 
undisturbed,  to  great  size,  crowding  the  tongue  out  of  its  position,  rising 
above  the  level  of  the  teeth,  and  protruding  through  the  muscles  of  the 
chin  until  it  appears  beneath  the  skin  above  the  hyoid  bone. 

The  only  method  of  treatment  is  to  evacuate  the  contents  and  cause 
an  obliteration  of  the  sac  by  inflammatory  adhesion.  The  Paquelin  cau- 
tery is  the  best  instrument  to  employ  in  their  removal.  Etherize  the 
patient,  introduce  the  gag,  lift  the  tongue  upward  with  the  forceps, 
protect  the  lips  and  teeth  by  means  of  flat  retractors,  seize  the  wall  of 
the  cyst  with  a  mouse-tooth  forceps,  and  with  the  platinum-knife  at  a 
red  heat  dissect  away  the  anterior  wall.  After  the  fluid  escapes,  dilate 
the  cavity,  and  make  a  thoroiigh  digital  exploration  of  the  sac.  The 
cautery-knife  should  now  be  carried  slowly  back  to  the  deepest  portions, 
searing  all  sides  of  the  cyst-wall.  The  wound  should  be  well  packed 
mth  a  single  piece  of  iodoformized  gauze.  The  after-treatment  consists 
in  changing  the  packing  every  twenty-four  to  forty-eight  hours,  and  at 
each  dressing  irrigating  the  cavity  with  l-to-2000  sublimate  solution. 

If  the  Paquelin  thermo-cautery  is  not  convenient,  seize  the  cyst-wall 
with  the  forceps  and  dissect  it  out  with  curved,  blunt  scissors.  Pack  the 
wound  firmly  with  iodoformized  gauze,  as  above.  Haemorrhage  may  be 
controlled  as  directed  in  wounds  of  the  tongue. 


THE  TONGUE  AND  BUCCAL  CAVITY.         489 

In  a  ranula  of  small  size,  cocaine  may  be  injected,  the  anterior  wall 
cut  away  with  the  scissors,  and  a  pellet  of  cotton  moistened  with  pure 
carbolic  acid  left  in  the  cavity  to  destroy  the  lining  membrane.  With 
the  first  dressing  a  tuft  of  gauze  should  be  packed  in,  and  this  should 
be  renewed  on  alternate  days  until  the  wound  closes. 

Tongue-Tie. — When  the  frsenum  extends  an  unusual  distance  toward 
the  tip  of  the  tongue,  or  is  so  narrow  that  it  checks  the  free  movements 
of  this  organ,  it  should  be  divided  in  the  following  manner :  Seize  the  tip 
of  the  tongue  with  a  dry  towel,  carry  it  upward  so  as  to  put  the  bridle 
on  the  stretch,  and,  with  a  curved  scissors,  divide  the  frsenum  from  one 
eighth  to  one  quarter  of  an  inch  nearer  to  the  iloor  of  the  mouth  than  to 
the  surface  of  the  tongue.  This  precaution  is  necessary  to  avoid  wound- 
ing the  ranine  vessels.     The  gag  may  be  used  if  required. 

A  congenital  defect,  very  rarely  observed,  is  the  adhesion  of  the 
tongue  to  the  floor  of  the  mouth.  The  adhesions  should  be  broken  up 
at  birth,  and  the  operation  repeated  daily  until  free  mobility  is  secured. 

Equally  rare  is  the  bifid  or  snake-tongue,  which  results  from  arrest  of 
development  or  failure  of  union  of  the  two  halves  from  which  this  organ 
is  formed.  The  edges  should  be  pared,  and  the  two  halves  united  in  the 
median  line  by  sutures. 

Tonsils. — Acute  tonsillitis  is  of  very  frequent  occurrence,  causing, 
in  a  varying  degree,  pain,  difficulty  of  deglutition,  and  interference  with 
phonation,  deglutition,  and  respiration. 

The  pathology  of  this  affection  consists  in  dilatation  of  the  blood- 
and  IjTnph-vessels,  emigration  of  leucocytes,  and  proliferation  of  the 
connective  tissue  and  other  cell-elements  of  the  tonsil.  The  gland  rapidly 
enlarges,  producing  great  tension  of  the  pillars  of  the  fauces,  and  projects 
toward  the  median  line,  at  times  filling  the  pharynx  and  crowding  the 
velum  upward  and  backward. 

Acute  tonsillitis  may  end  in  resolution,  the  gland  rapidly  diminishing 
to  its  normal  size,  or  in  ulceration  or  suppuration  (abscess),  or  the  acute 
process  may  subside  into  a  chronic  form  of  inflammation,  which  induces 
permanent  hypertrophy  of  the  organ. 

The  local  treatment  of  acute  tonsillitis  consists  in  the  application  of 
hot  water  as  a  gargle,  and  scarification  of  these  organs  when  the  tension 
is  sufficient  to  produce  great  pain.  The  internal  administration  of  aco- 
nite tincture  and  quinine  is  highly  recommended. 

Abscess  of  the  tonsil  should  be  opened  as  soon  as  its  presence  is  de- 
tected. The  discharge  of  pus  always  brings  great  relief.  If  the  symp- 
toms lead  to  the  suspicion  of  pus,  exploration  with  the  hypodermic  aspi- 
rator-needle should  be  made  to  determine  the  diagnosis.  The  internal 
carotid  artery  and  jugular  vein  are  well  back  from  the  tonsil,  on  a  level 
with  the  posterior  wall  of  the  pharynx. 

The  object  in  operating  early  is  to  prevent  oedema  of  the  glottis, 
which  may  occur  when  the  abscess  is  large  or  situated  behind  the  body 
of  the  tonsil.  A  more  remote  danger  is  rupture  of  the  abscess  during 
sleep,  and  escape  of  the  contents  into  the  larynx. 

Chronic  hypertrophy  of  the  tonsils  should  be  treated  by  partial  ex- 


490 


A  TEXT-BOOK   ON   SURGERY. 


cision,  repeated  as  often  as  may  be  deemed  necessary.  The  presence  of 
these  enlarged  organs  forces  the  patient  to  breathe  through  the  mouth, 
a  habit  which  often  induces  a  catarrhal  condition  of  the  mucous  mem- 
brane lining  the  respiratory  tract.  The  follicles  of  the  tonsil  discharge 
a  dirty,  cheesy  secretion,  which  at  times  becomes  retained  in  the  gland 
and  undergoes  calcification.  Calculi  one  fourth  of  an  inch  in  diameter 
have  been  removed  from  this  organ. 

Tonsillotomy. — Excision  of  the  tonsils  is  an  operation  practically  free 
from  danger.     In  children  who  can  not  control  themselves,  chloroform 
should  be  used,  the  gag  in- 
troduced, and  the  tongue 
depressed  by  an  assistant. 
The    operator   seizes    the 
exposed   portion    of    the 
organ  with  a  long  mouse- 
tooth  forceps  or  a  tenaculum,  pulls  it  slightly  toward 
the  median  line,  and  with  a  long-handled  pair  of  scis- 
sors, curved  pn  the  flat,  clips  off  from  one  third  to  one 
half  the  tonsil.     A  sponge,  fixed  in  a  holder,  dipped  in 
ice-water  and  pressed  on  to  the  bleeding  surface,  will 
arrest  the  heemon-hage. 

In  adults  local  ansestliesia  may  be  insured  by  cocaine 
hydrochlorate,  and  the  operation  performed  as  above,  with  much  greater 
facility,  since  the  intelligent  co-operation  of  the  patient  is  of  great  value. 
If  the  long  scissors  can  not  be  had,  a  long,  curved,  probe-pointed  bis- 


FiG.  514. — Mackenzie's  tousillotonK . 


toury  may  be  used  instead.  The  tonsil  is  lift- 
ed from  its  bed  by  a  tenaculum,  and  the  knife 
carried  through  as  above. 

Various  tonsillotomes  have  been  intro- 
duced, and  for  some  cases  are  very  useful,  but 
for  simplicity  and  general  application  the  in- 
struments above  selected  will  answer  all  pur- 
j)cses.  Among  the  best  of  the  tonsillotomes 
is  that  of  Mackenzie  (Fig.  514),  and  Tiemann's  instrument  (Fig.  515). 

The  tonsil  is  also  occasionally  the  seat  of  malignant  neoplasms,  as 
sarcoma  and  carcinoma,  while  cystic  tumors,  fibroma,  and  lymphoma  are 
among  the  benign  new  formations  which  attack  this  gland.  They  re- 
quire early  and  thorough  excision  in  aU  cases. 


CHAPTER  XV. 

THE   NECK. 

Wounds. — Wounds  of  the  neck  may  prove  rapidly  fatal  from  lisemor- 
rhage  inducing  syncope  ;  from  hgemorrhage  into  the  trachea,  causing  fatal 
asphyxia  ;  from  the  entrance  of  air  into  the  veins  ;  or  from  injury  to  the 
cord,  at  or  near  the  medulla.  Death  from  sepsis  may  occur  as  a  more 
or  less  remote  sequence  of  a  wound  in  this  region. 

Treatment. — The  immediate  indications  are  to  arrest  hemorrhage  at 
once,  and  prevent  asphyxia,  either  by  obstruction  of  the  trachea  or  the 
admission  of  air  into  the  veins.  Hsemorrhage  should  be  controlled  by 
pressure  directly  in  the  wound,  until  the  injured  vessels  can  be  secured 
by  the  ligature.  The  entrance  of  air  into  the  veins  must  be  carefully 
prevented,  by  constant  pressure  on  the  cardiac  side  of  the  lesion,  until 
the  forceps  have  been  successfully  applied  at  the  bleeding  point. 

When  the  wound  is  incised  or  lacerated.,  and  is  above  the  hyoid  bone 
and  has  severed  the  hyoid  muscles,  in  addition  to  the  prevention  of 
hsemorrhage  into  the  larynx  the  tongue  must  be  drawn  forward,  for 
when  these  muscles  are  divided  it  falls  back  upon  the  glottis,  and  may 
occlude  the  larynx.  If  the  trachea  is  opened,  the  edges  of  the  wound 
should  be  held  apart  with  tenacula,  the  head  dropped  over  the  end  of  a 
table  (Fig.  44),  any  clots  removed,  and  artificial  respiration  practiced  by 
Sylvester's  method  (page  31).  In  the  closu:-e  of  all  wounds  of  the  neck 
the  antiseptic  precautions  should  be  taken,  and  drainage  secured.  When 
the  pneumogastric,  hypoglossal,  or  other  important  nerves  have  been 
divided,  the  ends  should  be  brought  together  by  a  delicate  silk  suture. 
It  is  also  advisable  to  unite  the  ends  of  divided  muscles  by  sutures. 
An  incised  wound  of  the  oesophagus  should  be  closed  immediately. 
Lacerated  wounds  of  this  tnbe  should  be  allowed  to  close  by  granulation. 
Difficulty  in  deglutition  follows  severe  wounds  of  the  throat,  not  infre- 
quently necessitating  the  introduction  of  liquid  food  through  the  oeso- 
phageal tube,  or  feeding  by  the  rectum. 

Punctured  wounds  of  the  neck  should  be  dressed  antiseptically,  and 
compression  employed  to  arrest  hemorrhage.  If  this  does  not  succeed, 
the  ligature  should  be  applied. 

GunsTiot  wounds  should  be  treated  in  practically  the  same  manner. 
Missiles  of  small  caliber  deeply  lodged  should  be  left  alone,  since  they 
usually  become  encapsuled  and  remain  harmless.  When  superficial  and 
readily  detected,  they  should  be  extracted  by  the  forceps.  In  the  effort 
to  locate  a  bullet  it  is  always  important  to  place  the  parts  in  about  the 


492  A  TEXT-BOOK   ON  SURGERY, 

same  position  as  at  the  time  when  the  missile  penetrated.  If  this  is  not 
done,  the  muscles  and  fascia  become  displaced,  and  the  track  of  the 
wound  obstructed.  Gunshot  wounds  traversing  the  outer  lateral  and 
superficial  posterior  regions  of  the  neck  are  not,  as  a  rule,  dangerous.  If 
the  vertebral  column  is  involved,  the  prognosis  becomes  grave.  A  mis- 
sile traversing  the  tissues  of  the  neck  laterally,  and  in  front  of  the  ver- 
tebral column,  is  apt  to  inflict  fatal  injury. 

Abscess. — Abscess  of  the  neck  occurs  most  frequently  in  children,  and 
may  follow  an  injury,  or  result  from  an  idiopathic  inflammation  of  the 
tissues  of  this  region.  It  occurs  very  frequently  as  a  result  of  adenitis, 
or  periadenitis,  tonsillitis,  and  in  caries  of  the  upper  cervical  vertebrae, 
or  base  of  the  skull  (retro-pharyngeal  abscess).  It  may  also  follow  the 
lodgment  of  a  foreign  body  in  the  oesophagus.  Collections  of  pus  in  the 
upper  cervical  regions,  and  in  the  superficial  portions  of  the  root  of  the 
neck,  tend  to  become  encapsuled,  or  may  open  ultimately  through  the 
integument.  Retro-pharyngeal  abscess,  if  left  alone,  not  infrequently 
travels  downward  along  the  deep  fascia  of  the  neck,  and  may  open  into 
the  mediastinum. 

The  diagnosis  of  abscess  in  the  neck,  from  the  various  tumors  which  are 
found  in  this  region,  depends  upon  the  febrile  movement  present  in  ab- 
scess, the  acute  and  persistent  character  of  the  pain,  and  fluctuation.  The 
value  of  exploration,  with  an  aspirator-needle  large  enough  to  carry  pus, 
should  not  be  lost  sight  of  in  the  effort  to  arrive  at  a  positive  diagnosis. 

The  treatment  is  evacuation,  either  by  the  method  of  aspiration  and 
hyper-distention  already  given,  or  by  puncture  or  incision,  and  free  drain- 
age. When  the  abscess  is  situated  in  a  portion  of  the  neck  rich  in  ves- 
sels, it  should  be  opened  by  cutting  carefully  down  upon  it,  so  that  any 
haemorrhage  encountered  may  be  immediately  and  readily  controlled.  If 
a  puncture  is  determined  upon,  the  knife  should  be  introduced  in  the  part 
farthest  from  the  vessels,  and  along  the  aspirator-  or  exploring-needle  as  a 
guide.  As  soon  as  the  sac  is  entered  by  the  instrument  it  is  withdrawn 
and  a  dull-pointed  dressing-forceps,  tightly  closed,  is  carried  into  the  ab- 
scess, when,  by  forcible  separation  of  the  jaws,  the  puncture  is  enlarged. 

The  finger  may  now  be  introduced,  or,  if  this  can  not  be  done,  the 
forceps  will  indicate  the  size  and  most  dependent  portion  of  the  sac.  If 
the  first  opening  has  not  been  made  at  the  lowest  part  of  the  abscess,  or 
is  not  so  situated  that  thorough  drainage  is  secured,  it  should  be  enlarged 
so  as  to  extend  this  far,  or  a  counter-opening  made  by  boring  through 
with  the  forceps  until  the  skin  is  distended  over  the  point  of  the  instru- 
ment, when  it  can  be  safely  incised.  Drainage  should  be  maintained, 
and  the  cavity  irrigated  with  l-to-3000  sublimate  solution. 

The  diagnosis  of  retro-pharyngeal  abscess  depends  upon  the  follow- 
ing symptoms :  Pain,  a  feeling  of  soreness  and  stiffness  in  the  neck, 
swelling,  with  protrusion  of  the  posterior  wall  of  the  pharynx  if  the  dis- 
ease is  high  up,  interference  with  deglutition  and  respiration.  In  the 
earlier  stages  ail  of  these  symptoms  will  not  be  present,  but  as  soon  as 
this  dangerous  condition  is  suspected  an  effort  should  be  made  to  locate 
the  abscess  by  palpation  and  asi)iration. 


THE   NECK.  493 

In  evacuating  the  pus  an  incision  should  be  made  in  the  pharynx,  as 
near  the  median  line  as  possible.  '\'\Tien  a  large  quantity  of  fliiid  is 
present  the  head  should  be  inclined  downward  as  the  incision  is  made, 
so  that  the  contents  of  the  abscess  may  not  gi-avitate  into  the  larynx. 
This  danger  may  be  ob\dated  by  partially  emj)tying  the  sac  by  the  aspi- 
rator before  the  incision  is  made.  AVhen  the  sac  extends  low  down  the 
neck  it  should  be  entered  and  drained  from  below.  Deep  retro-pharyn- 
geal  abscess  may  be  reached,  as  a  rule,  by  the  incision  and  dissection  laid 
down  in  the  operation  of  cesopJiagotomy. 

PhlegTnon  of  the  neck  demands  free  incision  in  all  cases,  when  such 
incision  does  not  encroach  upon  the  important  organs  of  this  region. 

Tumors  of  the  KecTc — Solid  and  Cystic — Lymphoraa. — Pathological 
changes  in  the  lymphatics  of  the  neck  account  for  the  large  majority  of 
swellings  in  this  region.  Lymphoma  of  the  neck  may  be  solid  or  cystic, 
benign  or  malignant. 

Tumors  of  the  cerrical  glands  may  comprise  simple  lymphoma,  the 
result  of  hyperti-ophy  and  hyperplasia  ;  tubercular  lymphoma,  lympho- 
sarcoma and  lymphangiectasis. 

Lymphoma  occurs  most  frequently  in  the  submaxillary  and  upper  ca- 
rotid triangle,  and  next  in  order  of  frequency  along  the  line  of  the  great 
vessels  beneath  the  mastoideus,  and  lastly  in  the  subclavian  region.  In 
some  instances  these  tumors  attain  enonnous  proportions,  filling  in  the 
neck  to  the  level  of  the  lower  Jaw  and  clavicle,  and,  if  not  removed,  pro- 
duce death  by  pressure  upon  the  respii'atory  apparatus  or  the  oesophagus. 

Fatty  tumors  are  apt  to  occur  upon  the  posterior  aspect  of  the  neck, 
and  occasionally  in  the  clavicular  region.  They  are  comparatively  i-are 
in  the  anterior  and  upper  triangles. 

Cystic  Tumors. — Cysts  of  the  neck  are  congenital  and  acquired. 

Congenital  cysts  are  rare.  The  form  most  fi-equently  obseiwed  is  that 
already  mentioned  as  a  dilatation  and  hypertrophy  of  the  lymphatic  ves- 
sels (lymphangiectasis).  They  are  usually  multilocular,  and  may  extend 
deeply  and,  at  times,  assume  enormous  proportions. 

Acquired  cysts  are  seen  chiefly  along  the  line  of  the  mastoid  muscles, 
having  a  tendency  to  occur  in  the  neighborhood  of  the  parotid  gland, 
less  frequently  in  the  subclavian  triangle. 

Cysts  resulting  from  extravasations  of  blood  may  also  occur  here,  and 
occasionally  distention  of  the  bursse  in  the  thyro-hyoid  region  produces 
cystic  tumors.  They  require  thorough  and  careful  dissection  to  secure 
the  removal  of  the  entire  cyst-wall. 

Thyroid  Body. — Hypertrophy  or  hyperplasia  of  this  organ  may  be 
partial  or  complete.  All,  or  a  part,  of  one  lateral  lobe  is  usually  af- 
fected ;  less  frequently  the  isthmus  is  alone  involved.  The  offshoots  of 
this  body  which  are  met  vrith  at  times  near  the  hyoid  bone,  near  the 
inner  edge  of  the  sterno-mastoid  muscle,  and  occasionally  dipping  down 
behind  the  oesophagus,  may  also  become  enlarged.  Goitre,  or  hroncho- 
cele,  is  usually  endemic,  and  attacks  females  more  often  than  males.  ISTo 
cUmate  or  condition  of  living  affords  a  positive  immunity  from  this  dis- 
ease, although  in  certain  localities,  as  in  the  valleys  of  Switzerland,  it  is 


494  A  TEXT-BOOK   ON  SURGERY. 

frequently  met  with.  The  cause  of  goitre  is  unknown.  It  is  j^rone  to  oc- 
cur in  those  whose  surroundings  are  damp  and  unwholesome  and  among 
the  poorly  fed.  The  influence  of  heredity  is  recognized  in  the  occurrence 
of  this  disease  in  the  children  of  jjatients  affected  with  bronchocele. 

A  goitre  may  be  solid  or  cystic.  In  solid  goitre  the  enlargement  may 
be  caused  by  a  general  hypertrophy  of  the  normal  elements  which  com- 
pose this  body,  or  some  of  these  elements  may  undergo  proliferation 
and  increase  at  the  expense  of  the  others.  When  the  tumor  is  hard  and 
tense,  it  is  called  fibrous  goitre,  and  in  this  form  the  chief  pathological 
change  is  an  increase  in  the  connective-tissue  elements  of  the  stroma. 

In  cystic  goitre  the  tumor  is  caused  by  the  accumulation  of  a  dark- 
brown  fluid  within  the  substance  of  the  organ.  There  may  be  one  or 
more  separate  collections  of  fluid,  although  a  maltilocular  arrangement 
is  most  common. 

The  diagnosis  of  goitre  is  not  difficult.  The  presence  of  a  tumor  in 
the  region  of  the  thyroid  body,  usually  unilateral,  occasionally  bilateral, 
moving  with  the  trachea  in  the  act  of  deglutition,  capable  of  very  percep- 
tible enlargement  during  coughing  or  any  prolonged  and  violent  expira- 
tory efl'ort,  are  symptoms  which  point  quite  clearly  to  bronchocele.  As 
to  determining  the  character  of  the  tumor,  one  must  depend  upon  pal- 
pation in  great  part,  and  also  upon  exploration  with  the  aspirator.  Fi- 
brous goitre  is  dense,  hard,  very  slightly  elastic,  often  presenting  irregu- 
larities in  surface.  Cystic  bronchocele  is  round,  smooth,  elastic,  movable, 
and,  even  when  the  capsule  is  greatly  distended,  fluctuation  is  percepti- 
ble. The  use  of  the  exploring-needle,  and  the  withdrawal  of  a  portion 
of  the  fluid  contents  for  microscopical  examination,  is  important  in  diag- 
nosis. 

The  fluid  from  a  cystic  goitre  varies  in  color  from  amber  to  dark 
brown  and  almost  black.  Under  the  microscope  crystals  of  cholesterin, 
crenated  red  blood-corpuscles,  large  compound  granular  cells,  leuco- 
cytes, etc.,  are  seen.  The  characteristic  contents  of  hydatid  cysts  are 
easily  recognized  and  excluded.  Fibro-cystic,  or  mixed  goitres,  possess 
some  of  the  characteristics  of  both  the  foregoing  varieties.  The  feeling 
of  solidity  is  not  so  great  as  in  the  fibrous,  and  is  less  elastic  and  with 
a  less  appreciable  sense  of  fluctuation  than  in  cystic  bronchocele. 

Sarcoma  and  carcinoma  of  this  organ  are  hard,  solid  tumors  of  rapid 
development,  steadily  increasing  in  size,  and  in  their  growth  binding 
the  invaded  organ  to  the  integument,  muscles,  and  fascia  of  the  neck. 
Abscess  would  have  a  previous  history  of  inflammation,  pain,  and  febrile 
movement.  Aneurism  of  the  carotid  appears  usiially  to  the  outer  side 
of  the  thyroid  region,  and  presents  the  symptoms  of  expansion  with 
the  heart's  systole,  the  aneurismal  thrill  and  murmur,  all  of  which  symp- 
toms disappear  after  pressure  upon  the  artery  on  the  cardiac  side  of  the 
tumor. 

The  diagnosis  of  other  cervical  tumors  may  be  considered  here.  Tu- 
bercular lymphomata  are  recognized  by  their  anatomical  locations,  by 
their  slow  process  of  development,  together  with  the  personal  and  family 
history  of  the  individual. 


THE  NECK.  495 

In  many  instances  these  tumors  of  the  glands  remain  quiet  for  a 
period,  and,  responding  to  some  irritation,  an  adenitis  and  periade- 
nitis are  developed,  whicli  rapidly  lead  to  the  formation  of  abscess. 
They  are  found  most  frequently  along  the  lower  border  of  the  inferior 
maxilla  in  the  lovrer  parotid  region,  along  the  under  surface  and  poste- 
rior border  of  the  sterno-mastoid  muscle,  and  in  the  subclavian  triangle. 

Metastatic  lymphoma,  secondary  to  epithelioma  or  other  malignant  dis- 
ease of  the  face,  will  be  recognized  by  the  history  of  the  case.  Lympho- 
sarcoma of  the  neck  is,  in  its  earlier  stages  of  development,  with  difficulty 
differentiated  from  simple  adenoma.  It  grows,  however,  with  much 
greater  rajoidity,  and,  by  its  tendency  to  become  fixed  to  the  suiTound- 
ing  tissiies,  suggests  its  malignant  nattire.  It  is  most  usually  located 
about  the  center  of  the  neck  and  beneath  the  sterno-mastoid  muscle. 

Treatment. — Cystic  goitre  does  not  yield  to  constitutional  measures. 
Solid  tumors  should  be  treated  by  the  administration  of  full  doses  of 
potassium  iodide.  If  marked  diminution  in  the  size  of  the  tumor  does 
not  follow  within  the  first  few  weeks  of  this  treatment  it  should  be  dis- 
continued. 

Bronchocele,  either  solid  or  cystic,  which  is  small  in  size  and  not  per- 
ceptibly increasing,  does  not  demand  surgical  interference.  Such  tumors 
should  be  kept  under  observation,  and  if  at  any  time  there  is  a  marked 
increase  in  size  operative  interference  is  called  for,  before  the  mass  has 
assumed  such  proportions  that  its  removal  involves  considerable  danger 
to  life.  According  to  Kocher,  another  contra-indication  to  surgical  inter- 
ference is  the  presence  of  a  goitre  involving  the  entu-e  organ,  since — al- 
though the  operation  may  be  recovered  from — death  results  in  from  one 
to  two  years,  from  the  development  of  a  strumous  condition  not  unlike 
that  known  as  myxoedema.  Physiological  experiments  have  shown  that 
a  like  condition  results  from  the  total  extirpation  of  the  thyi'oid  body  in 
animals.  Under  no  circumstances,  therefore,  is  a  complete  i-emoval  of 
this  body  Justifiable.  One  side  and  the  isthmus  may  be  removed,  and  in 
extreme  cases  both  lobes  may  be  extirpated,  provided  the  isthmus  is  left 
undisturbed. 

Another  contra-indication  is  calcareous  degeneration  of  a  considerable 
portion  of  the  mass,  causing  a  condition  of  friability  in  the  vessels  which 
renders  their  deligation  unsafe. 

Operation  —  Cystic  Goitre. — Make  a  perpendicular  incision,  about 
three  inches  in  length,  over  the  center  of  the  tumor.  Divide  the  integu- 
ment, fascia,  and  intervening  muscles  down  to  the  sac.  Upon  approach- 
ing this,  the  dissection  should  be  carried  on  between  two  anatomical  for- 
ceps, lifting  only  a  thin  bit  of  tissue  at  each  gTasp  of  the  instruments, 
and  looking  closely  for  any  vessels  which  may  run  upon  or  through  the 
anterior  wall  of  the  tumor.  When  the  wall  is  reached  it  should  be 
divided  in  the  same  manner,  and,  upon  the  escape  of  the  contents  thi'ough 
the  opening,  this  should  be  enlarged  by  introducing  the  dressing-forceps 
and  dilating.  The  opening  in  the  wall  should  be  about  one  inch  long. 
A  continuous  catgut  suture  should  be  earned  through  the  integument, 
stitching  this  to  the  edges  of  the  sac.     The  cyst  should  now  be  well  irri- 


496  A  TEXT-BOOK   ON   SURGERY. 

gated  with  l-to-5000  sublimate  solution,  and  rubber  drainage-tubes  in- 
troduced, one  into  the  deepest  and  another  in  the  upj)er  portion  of 
the  sac.  A  loose  sublimate  dressing  should  be  applied.  The  indica- 
tions for  changing  the  dressing  are  hsemorrhage,  rise  in  temperature 
above  103°  after  the  second  day,  and  for  purposes  of  cleanliness.  In 
two  of  my  cases  in  which  larger  cysts  were  evacuated  there  was  con- 
siderable febrile  movement  for  the  first  week  after  the  operation.  As 
the  cyst  becomes  filled  with  granulation- tissue,  the  tubes  should  be 
gradually  shortened. 

In  the  removal  of  a  solid  unilateral  goitre,  a  crucial  incision  is  prefer- 
able. This  should  be  very  free,  in  order  to  give  a  full  view  of  the  wound. 
The  dissection  should  expose  the  entire  anterior  surface  of  the  mass  be- 
fore attempting  to  get  beneath  it  at  any  point.  Care  must  be  taken  not 
to  tear  or  incise  the  substance  of  the  tumor,  since  it  bleeds  profusely,  and 
is  often  so  friable  that  it  will  not  hold  a  ligature.  The  object  of  the  ojper- 
ator  should  be  to  get  into  the  capsule  of  the  tumor.  Working  with  the 
dry  dissector  between  this  and  the  surface  of  the  neoplasm  much  bleed- 
ing may  be  avoided.  Whenever  a  vessel  is  seen  in  the  track  of  the  dis- 
section, it  should  be  seized  in  two  places  with  the  forceps  (the  narrow- 
Jawed  instrument,  Fig.  82,  is  preferable),  divided  between  them,  and  each 
end  tied  with  stout  catgut. 

In  lifting  the  tumor  the  operator  should  work  along  the  outer  side, 
and  pass  under  the  mass  from  this  aspect.  In  this  way  the  superior  and 
inferior  thyroid  vessels  may  be  ligatured  in  the  earlier  stages  of  the 
operation,  and  the  chief  source  of  bleeding  controlled.  The  presence  of 
the  recurrent  laryngeal  nerves,  as  they  pass  upward  on  either  side,  in  the 
space  between  the  trachea  and  oesophagus,  should  not  be  forgotten.  It 
is  not  always  possible  to  avoid  them,  but  by  keeping  close  to  the  capsule 
of  the  tumor  the  least  risk  will  be  incurred.  The  veins  passing  into  the 
mass  are  at  times  of  great  size,  and  the  walls  of  those  in  the  tumor  are  in 
some  cases  very  friable,  causing  much  annoyance  and  delay,  in  repeatedly 
breaking  down  under  the  ligature  and  recurring  haemorrhage.  In  one  of 
my  cases  the  internal  jugular  vein  was  involved  in  the  mass  to  such  an 
extent  that  it  was  necessary  to  tie  this  vessel  above  and  below,  and  divide 
it.  When  all  of  the  tumor  is  free,  except  the  isthmias,  this  should  be 
surrounded  with  a  small  elastic  ligature,  and  divided.  The  edges  of  the 
wound  are  now  closed  with  catgut,  the  drainage-tube  and  rubber  ligature 
brought  out  at  the  most  dependent  poi^tion  of  the  incision,  and  a  subli- 
mate dressing  applied.  The  ligature  comes  away  by  drawing  upon  it 
about  the  eighth  day. 

The  prognosis  from  this  operation  is  favorable  in  the  large  majority 
of  cases.  It  only  becomes  grave  in  the  larger  tumors,  and  the  chief  ele- 
ment of  gravity  here  is  the  exhausted  condition  of  the  patient,  resulting 
from  pressui'e  of  the  mass.  It  must,  however,  be  classed  among  the  more 
formidable  operations,  although  modern  surgery  has  greatly  reduced  the 
death-rate. 

In  the  removal  of  double  goitres,  if  the  two  tumors  are  of  large  size,  the 
two  operations  may  be  done  with  an  interval  of  two  or  three  weeks,  should 


THE   NECK.  497 

the  first  operation  be  unavoidably  prolonged.  In  the  double  simultane- 
ous operation,  the  better  incision  is  that  of  Kocher,  whose  magnificent 
achievements  in  thyroidectomy  leave  him  unquestionably  the  lirst  of 
surgeons  in  this  field.  It  is  Y-shaped,  the  oblique  prongs  running  from 
below  the  ear  on  either  side  and  uniting  at  the  most  convenient  point 
near  the  pomum  Adami  in  the  middle  line.  Thence  a  single  median 
incision  extends  down  to  and  somewhat  beyond  the  sternal  notch.  Re- 
flecting the  flaps,  the  masses  are  well  exposed.  The  intra-capsular  dis- 
section should  now  be  continued  as  Just  described. 

Hydatid  cysts  are  in  very  rare  instances  met  with  in  this  organ. 
They  should  be  treated  by  incision  and  drainage,  as  laid  down  in  the 
management  of  cystic  goitre.  When  the  tumor  is  of  small  size  (two 
inches  or  less  in  diameter),  aspiration  and  hyperdistention  with  1-to- 
5000  sublimate  solution,  or  l-to-40  carbolic  acid,  may  be  tried.  The 
fluid  should  be  at  once  withdrawn  and  compression  maintained  for  sev- 
eral days. 

In  carcinoma  and  sarcoma  of  this  body,  complete  thyroidectomy  is 
demanded,  when  the  neoplasm  is  limited  to  a  portion  of  the  gland. 
When  both  sides  are  invaded,  or  when  the  entire  lobe  on  either  side  is 
occupied  with  the  new  growth,  operation  is  of  doubtful  propriety,  not 
only  on  account  of  the  immediate  danger  attending  siich  an  extensive 
dissection,  bat  by  reason  of  the  fatal  termination  within  one  or  two 
years  of  those  cases  in  which  both  lobes  and  the  isthmus  have  been 
extirpated.  When  the  tissues  immediately  surrounding  the  tumor  are 
invaded,  surgical  interference  is  not  indicated. 

Exophthalmic  Goitre — Basedow's  or  Graves^ s  Disease. — In  this  dis- 
ease the  thyroid  body  is  increased  in  size,  chiefly  due  to  the  dilatation 
of  the  arteries  and  veins  in  its  substance.  There  is  a  varying  degree  of 
hyperplasia  of  the  glandular  substance  and  the  connective-tissue  stroma. 
This  condition  is  accompanied  by  violent  chronic  palpitation  of  the  heart 
and  protrusion  of  the  eyeballs.  The  cause  of  this  disease  is  not  known. 
It  is  generally  considered  to  be  a  nervous  disorder.  It  is  met  with  in 
women  about  twice  as  often  as  in  men.  After  death  the  heart  is  found 
to  be  hypertrophied  and  dilated.  The  size  of  the  thyroid  tumor  is 
greatly  diminished  after  death,  and  the  exophthalmos  disappears.  This 
form  of  goitre  is  not  amenable  to  surgical  treatment,  and  is  mentioned 
here  as  an  aid  to  the  more  accurate  diagnosis  of  these  forms  of  broncho- 
cele  which  may  be  relieved  by  operative  interference. 

In  the  medical  treatment  of  exophthalmic  goitre  the  galvanic  current 
directed  to  the  symj^athetic  ganglia  of  the  neck  is  highly  recommended. 
The  direct  current  is  employed,  one  electrode  being  placed  over  the 
spines  of  the  cervical  vertebrse,  while  the  other  is  passed  over  the  en- 
larged thyroid  from  the  sternum  to  the  lower  jaw.*  This  treatment 
should  be  supplemented  by  tonics,  out-of-door  life,  attention  to  increased 
nutrition  of  the  tissues,  and  abstention  from  all  violent  exercise  or  ex- 
citement. 

*  Dr.  Doughty,  of  Augusta,  Ga.,  has  met  with  gratifying  results  in  this  method  of 
treatment. 

32 


498  A  TEXT-BOOK  ON  SURGERY, 


The  Larynx  and  Trachea. 

The  operations  upon  these  organs  in  the  neck  are  thyrotomy,  laryn- 
gotomy,  laryngo-tracheofomy,  tracheotomy,  and  exsection  of  the  larynx. 
Thyrotomy  is  indicated  in  the  removal  of  neoplasms  or  foreign  bodies 
from  the  larynx,  which  can  not  be  reached  through  the  mouth  by  the  aid 
of  the  laryngoscope  and  forceps  or  snare.  The  patient  should  be  placed 
upon  the  table,  with  the  head  well  depressed.  Make  a  perpendicular 
incision  from  near  the  center  of  the  hyoid  bone,  exactly  in  the  median 
line  of  the  pomum  Adami,  as  far  down  as  the  cricoid  cartilage.  The 
bleeding  is  thoroughly  arrested,  and  the  two  wings  of  the  thyroid  carti- 
lage divided  exactly  in  the  angle  of  union.  This  should  be  done  with 
great  care,  in  order  to  avoid  wounding  the  vocal  bands,  which  are  at- 
tached on  either  side  of  the  median  line,  in  front.  If  at  this  stage  of  the 
operation  a  tenaculum  is  inserted,  on  either  side,  the  alse  may  be  drawn 
apart,  freely  exposing  the  interior  of  the  larynx.  In  closing  the  wound 
the  cartilages  are  not  included  in  the  sutures,  it  being  sufficient  to  bring 
the  edges  of  the  skin  together. 

In  laryngotomy  the  opening  is  made  through  the  crico-thyroid  mem- 
brane. It  is  indicated  in  oedema  of  the  glottis,  obstruction  of  the  larynx 
by  new  growths,  foreign  bodies,  and  exceptionally  in  rapid  inflammatory 
swelling  of  the  tonsils  or  ]5harynx,  with  occlusion  of  the  larynx. 

When  the  emergency  demands  it,  rapid  laryngotomy  may  be  per- 
formed as  follows :  Make  a  single  incision  from  the  notch  in  the  upper 
margin  of  the  thyroid  cartilage,  in  the  median  line,  to  the  lower  edge  of 
the  cricoid  ring,  then  turn  the  knife-edge  upward  and  thrust  the  point 
through  the  crico-thyroid  membrane.  A  hook  should  now  be  quickly 
inserted  on  either  side,  and  the  edges  of  the  wound  separated.  Traction 
not  only  opens  the  wound  in  the  membrane  to  admit  the  air  more  freely, 
but  it  also  arrests  the  bleeding.  When  tenacula  can  not  be  had,  a  fair 
substitiite  may  be  extemporized  from  wire,  or  the  ordinary  metal  hair- 
pin. The  opening  in  the  membrane  may  be  enlarged  by  a  transverse 
incision  when  necessary. 

When  expedition  is  not  urgent,  the  bleeding  from  the  wound  in  the 
integument  should  be  arrested  before  the  open- 
ing into  the  larynx  is  made. 

If  it  is  necessary  to  keep  the  wound  open, 
a  silver  trachea-canula  (Fig.  516)  should  be  in- 
serted. This  instrument  is  secured  by  a  tape 
tied  around  the  neck.  When  it  becomes  ob- 
structed, the  inner  canula  should  be  withdrawn, 
cleansed,  and  reinserted,  and,  if  necessary,  the 
larger  tube  remaining  in  the  larynx  should  be 

Fig.  51G. — Double  trachea-tube,         t      ""  i      n         j.       -ii  '        n  i  i  tttt. 

silver,  plain.  bi'ushed  out  With  a  Small  brush  or  mop.     When 

this  instrument  is  worn  it  should  be  carefully 
watched,  as  long  as  any  danger  of  its  becoming  obstructed  exists.  It 
may  be  worn  indefinitely  in  cases  of  permanent  laryngeal  stenosis. 


THE   LARYNX   AND   TRACHEA. 


499 


Laryngotomy  without  a  Tube. — When  a  canula  is  not  at  hand,  a 
needle,  armed  with  fine,  strong  silk,  should  be  passed,  on  either  side, 
through  the  integument  and  cricoid  membrane,  brought  out  through  the 
opening  in  the  larynx,  and  the  suture  tied.  It  is  best  to  employ  two 
sutures  in  each  side  of  the  wound.  These  may  be  tied  behind  the  neck, 
or  attached  to  bits  of  adhesive  plaster  and  fastened  to  the  integument,  so 
as  to  keep  the  wound  open.  A  strip  of  plaster  should  be  laid  on  each 
side  of  the  wound,  to  j)revent  the  thread  from  cutting  into  the  integu- 
ment. 

Laryngo-tracheotomy  (an  operation  rarely  performed)  consists  in 
extending  the  incision  of  laryngotomy  through  the  cricoid  cartilage,  and 
the  upper  one  or  two  rings  of  the  trachea. 

Tracheotomy  is  more  frequently  done  than  either  of  the  operations 
just  given.  The  tracliea  may  be  opened  (1)  above  the  isthmus  of  the 
thyroid  body,  the  upper  three  or  four  rings  being  divided ;  (2)  the 
isthmus  may  be  tied  with  a  double  ligature,  divided,  and  the  trachea 
opened  beneath  it ;  (3)  the  opening  into  the  tube  may  be  altogether  be- 
low the  isthmus. 

It  will  rarely  be  found  necessary  to  divide  the  isthmus.  The  opera- 
tion above  the  isthmus  is  simpler,  and  should  be  preferred  in  all  cases 
where  the  obstruction  is  in  the  larynx.  For  the  removal  of  a  foreign 
body  lodged  in  the  bifurcation  of  the  trachea,  or  in  either 
bronchus,  the  lower  procedure  should  be  adopted.  This  op- 
eration should  also  be  preferred  in  diphtheritic  croup  when 
all  other  measures  have  failed.  The  results  achieved  with 
the  laryngeal  tube  of  Dr.  O'Dwyer,  of  New  York,  justifies  a 
faithful  trial  with  this  instrument  before  resorting  to  the  for- 
midable operation  of  tracheotomy  in  diphtheritic  croup. 

Dr.  O'Dwyer's  directions  are  as  follows :  The  tubes  are 
of  various  sizes,  and  are  constructed  on  a  scale  (Fig.  517) 
somewhat  like  the  urethi-al  sounds.  No.  1  is  intended  for  a 
child  eighteen  months  old,  or  less  ;  No.  2,  between  eighteen 
months  and  three  years  ;  No.  3,  for  the  fourth  year ;  No.  4, 
for  the  fifth  year,  and  so  on. 

"VYhen  the  proper  tube  is  selected  for  the  case  to  be  oper- 
ated on,  a  fine  silk  thread  is  passed  through  the  small  hole 
near  its  anterior  angle,  and  left  long  enough  to  hang  out  of 
the  mouth,  its  object  being  to  remove  the  tube  should  it  be 
found  to  have  passed  into  the  o'sophagus  instead  of  the 
larynx.  The  obturator  is  then  screwed  tightly  to  the  intro- 
ducing instrument,  to  prevent  the  possibility  of  its  rotating 
while  being  inserted,  and  passed  into  the  tube. 

The  child  is  held  upright  on  the  nurse's  lap,  with  its  arms  secured  by 
the  sides  or  behind  the  back.  An  assistant  holds  the  head,  which  he 
inclines  backward  at  the  proper  time,  while  the  operator,  seated  in  front, 
inserts  the  gag  (Fig.  518)  well  back  between  the  teeth,  in  the  left  angle 
of  the  mouth,  and  opens  it  as  widely  as  possible,  without  using  undue 
force.     He  then  inserts  the  index-finger  of  the  left  hand,  which  serves  to 


500 


A  TEXT-BOOK   ON  SURGERY. 


elevate  the  epiglottis  and  guide  the  tube  into  the  larynx.     The  handle  of 

the  introducing  instrument  (Fig.  519),  held  close  to  the  patient's  chest 

in  the  beginning  of  the  operation,  is 
rapidly  elevated  as  the  glottis  is  ap- 
^S^m^^^K^'h.  preached,  and  the  tube  pushed  down- 

ward without  using  much  force.  It 
is  then  detached,  and  the  obturator 
fiG.  518.— Gatr.  \aL.  ,«^  ^^11  quickly  removed.  The  joint  in  the 
shank  of  the  obturator  is  for  the  pur- 
pose of  facilitating  this  part  of  the 

operation.     Lest  the  tube  should  also  be  withdrawn,  it  is  necessary  to 

keep  the  finger  in  contact  with  it. 


When  it  is  ascertained  with  certainty  that  the  canula 
is  in  the  larynx  (and  for  this  purpose  it  is  better  to  wait 
until  the  child  coughs,  or  until  it  is  evident  that  the 
dyspnoea  is  relieved),  the  finger  is  again  placed  in  con- 
tact with  it  and  the  thread  removed. 

It  is  important  that  the  attempt  at  introduction  be 
made  quickly,  as  respiration  is  practically  suspended  from  the  time  that 
the  finger  enters  the  larynx  until  the  obturator  is  removed.  It  is,  there- 
fore, under  the  circumstances  much  safer  to  make  several  abortive  at- 
tempts than  one  prolonged  eft'ort,  even  if  successful. 

The  removal  of  the  canula  is  a  more  difficult  operation  than  its  intro- 
duction, owing  to  the  fact  that  the  aperture  of  the  tube  into  which  the 


extracting  instrument  (Fig.  520)  has  to  be  inserted  is  so 
much  smaller  than  that  of  the  larynx.  At  the  same  time 
more  deliberation  can  be  used,  and  an  angesthetic,  which  is 
never  necessary  for  the  introduction,  can  be  given  if  required. 
There  is  no  danger  whatever  of  these  tubes  slipping  through  into  the 

trachea,  even  if  used  on  older  children  than  those  for  which  they  are 

intended. 

Some  practice  on  the  cadaver  is  a  very  necessary  preliminary  to  using 

them  on  the  living  subject.    It  is  well  also  to  bear  in  mind  that  it  is  much 

more  difficult  to  reach  the  larj^nx  in  the  dead  than  in  the  living. 


ITigTi  Operation. — Place  the  patient  on  the  back,  in  such  a  position 
that  the  head  falls  well  over  the  end  of  the  table.     If  an  anaesthetic  is 


THE   LARYNX,   TRACHEA,   AND   BRONCHI.  50I 

not  given,  one  assistant  should  hold  the  extremities  immovable,  vhile  a 
second  steadies  the  head.  The  ojoerator  should  stand  to  the  patient's 
Tight,  facing  the  light.  It  is  important  that  the  head  be  held  so  that 
the  nose  and  symphysis  menti  will  be  directly  in  line  with  the  inter- 
clavicular notch  and  umbilicus,  for  if  this  precaution  is  not  taken  the 
trachea  may  be  displaced,  an  accident  which  might  lead  to  great  annoy- 
ance, especially  in  children,  in  whom  this  tube  is  always  very  small. 
The  incision  should  be  exactly  in  the  median  line,  commencing  at  the 
center  of  the  thyroid  cartilage  and  extending  downward  one  inch  and  a 
half,  or  more  if  necessary.  The  edges  of  the  wound  should  be  separated 
by  retractors,  and  the  incision  continued  down  to  the  tube.  All  bleeding 
should  be  arrested  by  the  forceps  and  ligature  before  the  trachea  is 
opened,  for  fear  of  suifocation  from  the  entrance  of  blood. 

In  some  subjects  it  will  be  found  that  the  isthmus  of  the  thyroid  body 
is  situated  so  high  that  an  opening  sufficiently  long  can  not  be  made 
without  displacing  it  downward.  This  may  be  done  by  dividing  with 
the  curved  scissors  the  muscular  and  ligamentous  bands  which  are  at- 
tached to  the  isthmus  below,  and  the  hyoid  bone  and  thyroid  cartilage 
above.  This  section  should  be  made  on  either  side  of  the  incision,  oppo- 
site the  first  ring  of  the  trachea.  After  all  bleeding  has  ceased,  the  knife 
should  be  carried  into  the  trachea  with  the  edge  directed  upward,  and 
the  two  or  three  upper  rings  divided. 

Low  Operation. — The  incision  through  the  integument  extends  from 
the  cricoid  cartilage  to  the  level  of  the  inter-clavicular  notch.  Separate 
the  sterno-thyroid  muscles  in  the  median  line,  and  carry  the  dissection 
carefully  down  to  the  trachea,  avoiding  the  isthmus  of  the  thyi'oid  body 
and  the  inferior  thyroid  vein,  a  branch  of  which  is  in  front  of  this  tube. 
The  anterior  jugular  vein  occasionally  is  in  the  median  line.  Any  of 
these  vessels  coming  within  the  line  of  incision  should  be  secured  with 
a  double  ligature  before  being  divided.  The  trachea  will  be  found  deep- 
ly situated,  and  should  be  incised  through  four  or  five  rings,  in  the  same 
manner  as  advised  in  the  preceding  operation.  If  a  trachea-tube  is  not  at 
hand,  the  operation  may  be  completed,  as  advised  in  laryngotomy,  with- 
out a  tube. 

Foreign  Bodies  i:^  the  Laeyxx,  Trachea,  akd  Bronchi. 

Foreign  bodies  in  the  respiratory  tract  are,  in  almost  all  instances, 
introduced  by  way  of  the  larynx,  into  which  they  may  fall  by  gravity 
or  be  drawn  in  by  the  suction-force  of  the  inspiratory  effort.  Occasion- 
ally they  enter  directly  from  without,  as  in  stab-  or  gunshot  wounds,  or 
may  make  their  way  in  from  the  oesophagus  by  perforation  or  from  the 
rupture  of  an  aneurism  or  abscess.  Pieces  of  coin,  buttons,  teeth,  seeds, 
threads,  pins,  blow-gun  darts,  shot,  particles  of  food,  etc.,  are  among  the 
most  frequent  substances  lodged  in  the  air-passages.  A  foreign  body 
may  lodge  just  behind  the  epiglottis,  across  the  rima  glottidis,  in  the 
ventricle  between  the  true  and  false  bands,  between  the  vocal  cords,  or, 
passing  these,  it  may  descend  into  the  trachea  or  bronchus.     If  it  be  a 


502  A  TEXT-BOOK  ON  SURGERY. 

solid  and  smooth  body,  it  will  pass  into  the  bronchus  and  continue  to 
descend  until  the  smaller  diameter  of  the  tube  arrests  its  progress.  Any 
substance  with  projecting,  sharp  edges,  or  long  and  pointed,  as  a  pin  or 
fish-bone,  may  become  lodged  across  the  windpipe  at  any  point. 

The  symptoms  of  foreign  body  in  the  air-passages  are  immediate 
and  remote.  Strangulation,  cough,  and  cyanosis  immediately  after  the 
escape  of  any  substance  backward  from  the  mouth  or  nose,  or  matter 
which  has  been  regurgitated  from  the  stomach,  always  suggest  the  en- 
trance of  foreign  matter  into  the  larynx  or  trachea.  In  some  cases  death 
ensues  almost  instantly  from  asphyxia.  In  others  the  symptoms  of 
strangulation  last  for  a  few  moments  and  then  disappear,  leading  the 
patient  or  attendant  to  believe  that  the  foreign  body  has  been  coughed 
orit  or  swallowed.  The  momentary  cyanosis  and  strangulation  are  caused 
by  spasm  of  the  laryngeal  muscles,  induced  by  direct  irritation  from  the 
foreign  body.  As  soon  as  these  relax  a  forcible  inspiratory  effort  may 
carry  the  substance  downward  to  the  trachea  or  bronchus,  or  the  expira- 
tory cough  may  have  discharged  it  into  the  mouth.  In  any  event,  the 
symptoms  of  asphyxia  disappear  unless  the  offending  substance  is  so 
large  that,  even  when  sucked  into  the  trachea,  it  completely  occludes  this 
tube.  The  remote  symptoms  of  foreign  bodies  in  the  air-passages  are 
chiefly  inflammatory.  Traumatic  trachitis,  bronchitis,  pneumonia,  gan- 
grene, and  abscess  may  ensue.  Abscess  and  gangrene  are  rare.  Bron- 
chitis is  inevitable,  and  localized  or  lobar  pneumonia  is  not  infrequent. 

The  diagnosis  may  be  determined  by  inspection,  palpation  (either 
direct  or  intermediate),  and  by  auscultation,  together  with  a  due  regard 
for  the  sensations  experienced  by  the  patient.  Inspection  is  only  possible 
with  the  laryngoscope.  Direct  palpation  is  only  possible  when  the  sub- 
stance is  lodged  in  the  larynx,  since  the  tip  of  the  finger  can  not  be  car- 
ried beyond  this  point. 

Auscultation  is  of  great  aid  to  diagnosis,  especially  when  the  body 
has  passed  deep  into  the  respiratory  tract.  Diminution  or  absence  of 
the  normal  vesicular  murmur  over  one  entire  lung  indicates  the  partial 
or  complete  occlusion  of  one  primary  bronchus  by  the  foreign  body.  If 
this  interference  is  limited  to  only  a  portion  of  the  lung,  the  indication 
is  that  the  body  has  passed  into  one  of  the  subdivisions  of  the  bronchus. 

The  compensatory  increase  of  the  normal  vesicular  respiration  in  the 
opposite  lung  will  be  proportioned  to  the  interference  with  the  function 
of  the  affected  side.  When  a  narrow  body  becomes  lodged  in  the  trachea 
or  bronchus,  its  ijresence  is  indicated  by  a  sibilant  or  hissing  sound, 
heard  with  greatest  intensity  over  the  point  of  lodgment,  and  carried 
upward  and  downward  with  the  expiratory  or  inspiratory  movement. 

The  presence  of  pain  persisting  in  a  given  locality  points  to  the  seat 
of  lodgment  of  the  foreign  substance.  Persistent  spasm  of  the  larynx 
untU  tolerance  is  acquired  suggests  lodgment  in  the  ventricle  of  this 
organ. 

Treatment.  — The  immediate  indication  is  the  prevention  of  fatal  as- 
phyxia, and  this  may  require  rapid  laryngotomy  or  tracheotomy,  and, 
in  exceptional  instances,  the  resuscitation  of  the  patient  by  the  method 


THE  LARTXX,  TRACHEA,  AXD  BROXCHI.        503 

of  Sylvester  (page  31).  As  soon  as  this  danger  is  obviated,  tlie  removal 
of  the  foreign  body  may  be  undertaken.  It  is  weU  to  remember  that  in 
a  few  instances  symptoms  of  asphyxia  have  been  produced  from  the 
epiglottis  having  been  dra^^Ti  into  the  rima  glottidis  by  a  powerful  in- 
spiratory effort. 

When  fatal  asphyxia  is  not  threatened,  no  immediate  operation  is  in- 
dicated. The  patient  should  be  turned  head  downward  and  violently 
shaken,  and  at  the  same  time  made  to  cough  or  sneeze.  If  the  substance 
is  smooth  or  heavy,  it  may  be  dislodged  and  expelled  in  this  manner. 

If  this  procedure  is  unsuccessful,  the  question  of  operative  interfer- 
ence should  be  considered.  If  the  body  can  be  located  in  the  larynx,  it 
can  readily  be  removed  by  the  operation  of  thyrotomy  if  the  patient  is 
a  child,  or  by  laryngotomy  and  the  introduction  of  the  little  finger  into 
the  organ  through  the  wound  in  the  adult,  pushing  the  offending  sub- 
stance upward  into  the  jjharynx.  Either  of  these  procedures  is  prac- 
tically free  from  danger.  When  the  foreign  body  has  passed  into  the 
trachea  or  bronciii,  the  necessity  for  operative  interference  will  depend 
upon  its  size,  shape,  and  location.  If  it  is  small,  and  produces  no  marked 
disturbance  of  respiration,  and  is  deeply  lodged,  no  effort  should  be 
made  to  remove  it,  for  the  following  reasons  :  When  small,  it  is  not  apt 
to  iniiict  serious  damage  ;  the  tracheotomy  and  the  inti'oduction  of  in- 
struments into  the  respiratory  tract  are  dangerous  operations  ;  lastly,  the 
uncertainty  of  finding  or  dislodging  a  small  body  should  be  taken  into 
consideration. 

When,  however,  the  character  of  the  foreign  body  is  such  that  its 
presence  is  a  source  of  great  danger  to  the  patient,  and  it  can  not  be  re- 
moved without  operation,  surgical  interference  is  demanded.     The  posi- 
tion for  the  patient  is  the 
same  as  for  ti'acheotomy, 
and  this  operation  should 
be  done  as  low  down  as 
possible.     When  the    ti'a- 

Chea    is    opened,    the    little  Fis.  521.— Forceps  for  removing  foreign  bodies 

X*  1         T  n      1  '    1  trom  the  trachea  and  bronciii 

nnger  should  be  earned 
downward  to  the  bifurca- 
tion in  the  hope  of  locating  the  body,  and,  if  discovered,  it  should  be 
grasped  with  a  pair  of  forceps  and  removed.  If  it  is  not  encountered 
below,  the  upper  portion  of  the  tube  should  be  examined  in  the  same 
way.  If  it  can  not  be  reached  by  the  finger,  the  angular  alligator-forceps 
(Fig.  521)  should  be  carried  into  the  bronchial  tubes,  carefully  regarding 
any  ari'est  in  the  progi'ess  of  the  instrument. 

A  solid  or  large  body  may  be  felt  and  seized  vsdthout  great  difficulty. 
A  small,  light  substance  may  be  touched  without  any  sense  of  resistance 
to  the  hand  of  the  operator.  If  it  can  not  be  recognized,  the  point  of 
the  instrument  should  be  carried  into  the  bronchus  in  which  the  body  is 
located,  the  jaws  separated,  and,  while  open,  earned  about  half  an  inch 
further  in,  and  then  closed  and  withdrawn  in  order  to  see  if  the  object 
has  been  grasped.     This  manoeuvre  is  repeated  several  times  until  the 


504 


A  TEXT-BOOK   ON  SURGERY. 


whole  length  of  the  bronchus  has  been  searched.  If  the  foreign  body  is 
not  found,  it  will  be  judicious  to  search  in  the  opposite  bronchus,  for  it 
is  possible  for  it  to  have  been  dislodged  in  the  course  of  the  exploration, 
and  carried  by  the  respiratory  effort  into  the  trachea  and  down  into  the 
other  tube.  If  proper  forceps  can  not  be  obtained,  a  loop  of  silver  wire 
may  be  used. 

The  exploration  of  the  trachea  should  be  done  with  great  care  not  to 
inflict  unnecessary  violence  upon  the  mucous  membrane.  The  search 
should  not  be  prolonged  more  than  from  thirty  minutes  to  one  hour. 

If  the  body  is  removed,  the  wound  may  be  left  to  heal  by  granulation, 
simply  closing  it  with  adhesive  strips,  or,  if  the  patient  has  borne  the 
ansesthetic  well,  it  will  be  better  to  stitch  the  trachea  with  catgut,  and 
the  edges  of  the  wound  separately  with  the  same  substance.  If  the  object 
is  not  found,  the  tracheal  wound  should  be  kept  open  by  inserting  a  large 
trachea-tube,  or  by  sewing  the  tracheal  rings  to  the  edges  of  the  divided 
integument  and  keeping  the  wound  open  by  tying  the  strings  behind  the 
neck. 

Figs.  522  and  523  exactly  represent  an  air-gun  dart  which  was  lodged 
in  the  right  bronchus  of  a  boy  twelve  years  old,  who  came  under  my 

care  in  1884.*  In  the  act  of  filling 
his  lungs  to  project  the  dart  from  the 
gun  it  was  carried  into  the  trachea. 
Spasm  of  the  laryngeal  muscles  fol- 
lowed for  a  few  moments,  with  marked 
cyanosis.  After  this  there  were  no 
symptoms  of  disturbance  beyond  a 
slight  cough.  I  performed  tracheot- 
omy at  the  lowest  point  possible,  dis- 
lodged the  body  by  forceps  carried 
into  the  bronchus,  when  it  was  eject- 
ed during  a  violent  paroxysm  of 
coughing.  The  wound  was  left  to 
close  by  granulation. 
Laryngectomy,  or  exsection  of  the  larynx,  although  a  formidable 
operation,  is,  under  certain  conditions,  Justifiable.  It  may  be  partial  or 
complete.  According  to  Cohen's  excellent  article,t  com]Dlete  laryngec- 
tomy has  been  performed  ninety-one  times.  The  gravity  of  the  procedure 
may  be  estimated  from  the  fact  that  over  one  third  of  all  the  cases  died 
within  eight  days  of  the  operation. 

The  conditions  which  justify  the  operation  are,  the  invasion  of  this 
organ  by  malignant  neoplasm,  and,  in  rare  instances,  destructive  chon- 
dritis, with  infiltration  and  threatened  occlusion  of  the  resjjiratory  tract. 
If,  after  a  careful  study  of  the  case,  the  surgeon  is  convinced  that  there 
is  a  fair  probability  of  relief  from  pain  and  prolongation  of  life  by  the 
removal  of  the  diseased  structures,  greater  than  he  would  be  likely  to 


Fia.  522.— Dart, 
aa  it  cime  from 
the  bronchus. 


Fio.  523.— The  same, 
before  it  entered. 


*  "  New  York  Medical  Journal,"  Noyember,  1884,  p.  487. 

t  Ashhurst's  "  Encyclopaedia  of  Surgery,"  vol.  v.     "William  Wood  &  Co.,  New  York. 


THE  LARYNX,  TRACHEA,  AND  BRONCHI. 


505 


obtain  by  the  palliative  operation  of  tracheotomy,  he  is  justified  in  ad- 
vising the  operation.  When  the  tissues  about  the  larynx  are  widely 
infiltrated  with  the  malignant  neoplasm,  the  operation  is  not  justifiable. 

It  is  performed  as  follows :  The  patient  is  anaesthetized  with  ether,  by 
the  mouth,  and,  when  once  fully  anaesthetized,  the  narcosis  should  be 
continued  by  the  rectum.    The  first  step  is  to  reach  the  trachea  at  a  point 
sufficiently  low  to  be  well  out  of  the  diseased  zone.     An 
incision  is  made  as  in  tracheotomy,  and  a  Trendelen- 
burg's tube  (Fig.  524)  is  introduced.     The  end  of  this 
tube,  which  is  car- 
ried into  the  tra- 
chea, is  surroiind- 
ed  by  a  rubber  bal- 
loon, which,  after 
its  introduction,  is 
inflated,  thus  com- 
pletely tamponing 
the    trachea    and 
preventing  the  es- 
cape of  blood  into  the  bronchi. 
may  be  used  if  needed 


Fio.  524. — Trendelenburg's  trachea-tampon,  with  inhaling-apparatus  attached. 


The  attachment  for  inhalation  of  ether 
The  organ  is  best  exposed  by  a  crucial  incision, 
and  all  bleeding  should  be  arrested  as  the  operation  proceeds.  It  is  best 
to  seize  all  vessels  between  two  forceps,  divide  and  tie  them  as  directed 
in  the  operation  for  the  removal  of  goitre. 

A  trachea-tube  should  be  inserted  after  the  exsection  is  completed. 
Alimentation  is  carried  on  through  an  oesophageal  tube,  or  by  introduc- 
tion into  the  rectum. 

Partial  laryngectomy  is  performed  in  the  same  general  way  as  the 
preceding  operation. 

Neoplasms  of  the  Larynx  and  TracTiea. — Almost  every  form  of  new 
growth  Las  been  removed  from  the  larynx.  No  portion  of  the  organ  is 
exemj)t.  The  symptoms  are  referable  to  the  location  of  the  neoplasm 
and  to  its  size,  and  in  a  certain  sense  to  its  shape.  Those  situated  upon 
the  vocal  bands  are  first  noticed,  on  account  of  interference  with  the 
voice.  A  neoplasm  may  develop  in  the  ventricle,  and  not  be  noticed 
until  it  encroaches  upon  the  cords.  Dyspnoea  occurs  earlier  when  the 
tumor  is  situated  upon  the  rima  glottidis. 

Cough  is  not  a  jirominent  symptom,  for  the  reason  that  the  slow  and 
progressive  develoj^ment  of  the  neoplasm  gradually  accustoms  the  larynx 
to  its  presence.  Spasmodic  cough  does,  however,  occur  in  pedunculated 
growths,  which  are  moved  to  and  fro  as  the  air  rushes  in  and  out  of  the 
larynx. 

The  diagnosis  may  be  made  from  the  symptoms  detailed,  but  chiefly 
by  palpation  and  the  laryngoscope.  The  location  is  simple,  but  the  dif- 
ferentiation as  to  the  character  of  the  growth  is  at  times  difficult.  Papil- 
lomata  are  most  frequently  met  wath,  and  papilloma  in  the  larynx  pos- 
sesses the  same  general  properties  observed  in  these  growths  in  more 
exposed   quarters.      They  are   most   commonly  found  upon  the  vocal 


506  A  TEXT-BOOK  ON  SURGERY. 

bands.  The  tumor  may  appear  in  the  mirror  as  a  single  wart-like  fun- 
gus, or  pinkish-gray  tuft  upon  the  cords  or  laryngeal  wall,  or  there  may- 
be several  which  fill  a  great  part  of  the  oiaening.  The  fibroid  laryngeal 
polypi  {fibromata)  are  chielly  pyriform,  pedunculated,  and  smooth,  iu 
location  and  color  resembling  the  pai^illomata. 

EncTiondromata  of  the  larynx,  less  frequently  observed  than  the  two 
preceding  neoplasms,  are  developed  from  the  cartilage  proper  of  the 
larynx.  They  are  usually  seen  in  the  vicinity  of  the  crico-arytenoid 
articulation.  Cystic  tumors  are  rare.  Occlusion  of  the  duct  of  the  sac- 
culus  taryngis  will  lead  to  the  appearance  of  a  tumor  in  the  ventricle, 
between  the  true  and  false  bands.  Other  cysts  may  result  from  simple 
follicular  occlusion.  Telangiectasis,  or  angioma,  is  a  still  rarer  form  of 
laryngeal  tumor.  Carcinoma  {epithelioma)  is,  unfortunately,  not  a  rare 
disease  of  this  organ.  Sarcoma  is  very  rarely  met  with.  EpitTielloma  of 
the  larynx,  in  common  with  all  malignant  (as  well  as  benign)  neoplasms, 
occurs  chiefly  at  the  upper  portions  of  the  organ. 

The  treatment  of  all  forms  of  benign  tumors  of  the  larynx  is  their 
removal  with  the  knife,  scissors,  the  snare,  or  caustics.  Removal  of 
malignant  growths,  to  an  extent  sufficient  to  prevent  recurrence,  without 
a  total  or  partial  laryngectomy,  is  rarely  possible.  Benign  growths, 
especially  the  smaller  new  formations,  may  be  removed  best  by  chromic- 
acid  crystals  directly  applied,  at  frequent  sittings.  A  small  pellet  of 
cotton  is  attached  to  the  end  of  the  applicator,  and  a  particle  of  chromic 
acid,  of  convenient  size,  is  picked  up  on  this  and  carried  down  to  the 
tumor.  The  crystals  adhere  to  the  Unt  until  they  come  in  contact  with  a 
moist  surface.  In  carrying  the  instrument  through  the  mouth,  care  must 
be  taken  to  avoid  touching  the  mucous  surfaces.  Epithelioma,  in  its 
early  stages  of  development,  may  be  successfully  destroyed  by  this 
escharotic.  The  operator  should  take  advantage  of  the  anaesthetic 
properties  of  cocaine  to  render  Hhe  pharynx  and  larynx  tolerant  of 
manipulation.  Nitrate  of  silver  may  also  be  used,  but  is  inferior  to 
chromic  acid. 

Avulsion,  or  tearing  away  the  neoplasm,  is  a  useful  and  frequently- 
employed  method.  For  this  purpose  various  forms  of  forceps  have  been 
used.  Pedunculated  tumors  may  be  snared  and  cut  away  with  the 
wire  loop  of  Jarvis.  Fibromata  often  adhere  so  tenaciously  that  they 
can  not  be  torn  away  without  damage  to  the  larynx.  Care  should  be 
taken  to  regulate  the  force  so  that  injury  to  the  vocal  bands  or  the  smaller 
cartilages  may  be  avoided. 

The  operation  of  thyrotomy — heretofore  described — gives  the  best 
command  of  the  cavity  of  this  organ,  and  allows  the  more  thorough  and 
safe  removal  of  the  neoplasm. 

Neoplasms  similar  in  character  to  those  found  in  the  larynx  may 
occur  in  the  trachea  and  bronchi.  The  location  of  the  new  growth  may 
be  determined  from  the  physical  signs. 

The  treatment  is  strictly  surgical,  and  involves  jjhysical  exploration 
of  the  respiratory  tract,  with  avulsion  or  excision  of  the  growth,  or  the 
introduction  of  the  trachea-tube  to  prevent  asphyxia. 


PHARYKX  AND   (ESOPHAGUS.  507 

PhAPvYNX  AyO   OESOPHAGUS. 

Pharynx. — Neoplasms  of  the  walls  of  this  cavity  are  comparatively 
rare.  They  occur  usually  in  the  vault,  and  are  attached  to  the  mucous 
membrane,  or  periosteum,  beneath  the  basilar  process.  The  treatment 
consists  in  removal  by  the  snare  or  by  the  galvano-cautery.  When  a 
tumor  of  any  considerable  size  is  to  be  removed  by  the  knife,  it  may  be 
necessary  to  perform  tracheotomy,  insert  a  tube,  and  tampon  the  pharynx 
as  a  preliminary  measure.  In  some  instances  deligation  of  both  external 
carotid  arteries  is  advisable.  In  one  instance  I  was  compelled  to  do  this 
to  avert  almost  fatal  hsemorrhage  from  a  very  vascular  tumor  of  this  re- 
gion. In  this  case  the  tumor  was  exceedingly  well  exposed  by  splitting 
the  soft  palate  in  the  median  line,  and,  with  a  keyhole-saw,  I  then  made 
parallel  sections  through  the  bony  jialate,  one  quarter  of  an  inch  on  either 
side  of  the  median  line,  for  a  depth  of  three  quarters  of  an  inch.  The  por- 
tion between  these  lines,  together  with  the  contiguous  portion  of  the 
vomer  to  which  the  neoplasm  was  attached,  was  excised. 

Foreign,  bodies  are  not  infrequently  lodged  in  this  organ.  They  may 
be  discovered  by  inspection  with  the  pharyngoscope,  or  felt  with  the 
index-finger.  Retropharyngeal  abscess  follows  in  a  certain  proportion  of 
cases  in  which  the  foreign  body  is  not  removed  soon  after  its  introduction. 

The  treatment  is  removal  by  the  aid  of  the  mirror  and  the  curved 
forceps. 

ffiSOPHAGUS. 

Rupture  of  the  oesophagus,  though  several  instances  are  recorded,  is 
exceedingly  rare.  The  accident  occurs  in  forced  eiforts  at  deglutition 
after  great  distention  of  the  stomach  by  over  eating  and  di'inking.  The 
symptoms  are  intense  pain  in  the  region  of  the  rupture — which  is  usually 
in  the  long  axis  of  the  tiibe  and  near  the  diaphragm— followed  by  rapid 
and  fatal  collapse.  Vomiting  does  not  occur,  although  the  contents  of 
the  stomach  may  be  emptied,  in  part,  into  the  mediastinum.  Surgical 
interference  is  not  justifiable. 

Foreign  Bodies. — The  lodgment  of  bodies  in  the  oesophagus,  result- 
ing in  partial  or  complete  occlusion,  is  of  frequent  occuiTence.  The 
symptoms  depend  in  great  part  upon  the  character  of  the  foreign  sub- 
stance. A  sharp  and  narrow  body — as  a  bone,  pin,  needle,  or  splinter  of 
wood — will  prodiice  pain  at  the  seat  of  lodgment,  but  will  allow  the  pas- 
sage of  liquid  and  semi-solid  ingesta.  Soft,  compressible  particles  of 
large  size  may  completely  occlude  the  tube,  and  cause  pressure  upon  the 
trachea  sufiicient  to  induce  marked  asphyxia.  The  diagnosis  must,  in 
part,  be  based  ujjon  these  symptoms  and  the  history  of  the  accident. 
Pressure  over  the  seat  of  lodgment  of  a  sharp  substance  will  exaggerate 
the  sense  of  pain,  while  the  inability  to  swallow  liquids  will  indicate  the 
complete  occlusion  of  the  tube.  The  introduction  of  the  elastic  oesopha- 
geal sound  (Fig.  525)  will  demonstrate  the  presence  of  any  occluding  body. 

In  order  to  introduce  this  instrument,  lubricate  it  with  the  white  of  an 
egg,  and  cause  the  patient  to  throw  the  head  back  so  as  to  bring  the  axis 


508  A  TEXT-BOOK   ON   SURGERY. 

of  the  mouth  and  pharynx  in  line  with  that  of  the  oesophagus.  Insert  the 
bougie  so  that  the  point  will  glide  over  the  root  of  the  tongue  and  strike 
the  posterior  wall  of  the  pharynx  behind  the  larynx.  The  tongue  should 
not  be  drawn  out  of  the  mouth.  Spasm  of  the  glottis  will  prevent  the 
instrument  passing  into  the  larynx,  while,  if  kept  in  the  median  line  and 
pushed  carefully  down,  it  will  pass  into  the  oesophagus. 


Fig.  525.— (Esophageal  sound  and  bulbs. 


The  location  of  the  foreign  body  will  be  indicated  by  stoppage  of  the 
sound.  The  prognosis  is  favorable  when  the  occlusion  is  not  complete. 
If  the  distention  is  great  enough  to  interfere  with  respiration,  the  gravity 
of  the  accident  is  increased.  Infiammation,  abscess,  and  perforation  of 
the  oesophagus  may  occur  if  the  obstruction  is  not  removed  within  the 
first  few  days. 

Treatment. — When  a  foreign  body  is  lodged  in  the  oesophagus,  and 
does  not  completely  occlude  its  caliber,  it  may  usually  be  dislodged  by 
producing  emesis.  If  there  is  complete  obstruction,  the  act  of  vomiting 
should  not  be  excited,  nor  is  the  employment  of  a  sound  or  bougie  to 
push  the  object  into  the  stomach  permissible. 

When  the  substance  lodged  does  not  occlude  the  oesophagus,  and  eme- 
sis has  failed  to  dislodge  it,  the  umbrella-probang  (Fig.  526)  should  be 
introduced.  This  instrument  is  lubricated,  closed,  and  passed  into  the 
oesophagus  until  the  bristles  are  well  beyond  the  point  of  lodgment,  Avhen 
they,  by  pressure  upon  the  whalebone  handle,  are  projected,  completely 


Fig.  528. — Bristle  probang,  for  removing  foreign  bodies. 

filling  the  tube,  and  the  probang  withdrawn.     If  the  in-    s^ 
troduction  of  this  instrument  is  difiicult  or  painful,  an 
gesthetic  should  be  administered. 

In  case  of  complete  obstruction,  where  the  danger  of  inanition  is 
threatened,  or  where  pressure  u]3on  the  trachea  must  be  relieved,  cesoph- 
agotomy  should  be  performed. 

The  incision  should  be  made  about  five  inches  in  extent,  along  the 
anterior  border  of  the  left  stei'uo-mastoid  muscle.  If  the  occlusion  is 
high  up,  the  center  of  this  cut  should  be  opposite  the  point  of  obstruc- 
tion. If  it  is  below  the  sternal  level,  the  tube  should  be  opened  as  low 
down  as  possible.  If  necessary,  the  sternal  origin  of  the  mastoideus  may 
be  divided.  The  carotid  artery  and  jugular  vein  are  left  to  the  outer 
side.  The  thyroid  body  should  be  drawn  outward  or  lifted  upward. 
The  omo-hyoid,  thyro-hyoid,  and  sterno-hyoid  muscles  should  be  held 
to  the  inner  side.  A  sound  should  now  be  introduced  into  the  oesopha- 
gus, in  order  to  serve  as  a  guide  to  the  operator.     The  opening  should  be 


(ESOPHAGUS.  509 

made  on  the  lateral  and  posterior  aspect  in  order  to  avoid  the  recurrent 
laryngeal  nerve.  With  the  finger  introduced  into  the  wound,  the  foreign 
body  may  be  felt  and  removed  by  the  alligator-forceps.  It  is  usual  to 
leave  the  wound  open.  For  the  first  three  or  four  days  after  the  opera- 
tion the  patient  must  be  fed  by  a  tube  introduced  throiigh  the  mouth 
and  beyond  the  wound. 

Stricture. — Stricture  of  the  oesophagus  may  be  spasmodic  or  organic. 
The  irritation  caused  by  an  organic  stricture  may  not  only  exaggerate 
the  degree  of  constriction  by  exciting  spasm  of  the  muscular  fibers  of 
this  tube  in  the  immediate  vicinity  of  the  stricture,  but  also  at  points 
remote  from  the  seat  of  the  organic  lesion. 

Organic  stricture  is  comparatively  rare.  It  may  result  from  inflam- 
mation of  the  oesophagus  caused  by  the  ingestion  of  scalding  water,  strong- 
acids  or  alkalies,  the  lodgment  of  foreign  bodies,  by  wounds  of  the  neck, 
the  presence  of  a  neoplasm,  an  aneurism,  or  by  the  local  expression  of 
some  general  dyscrasia,  as  in  syphilis. 

The  diagnosis  is  determined  by  interference  with  deglutition  and 
by  physical  exploration  wth  the  bulbous  bougies. 

The  jjrognosis  is  unfavorable,  although  a  fatal  termination  may  not 
be  reached  for  a  considerable  period. 

The  treatment  consists  in  dilating  the  stricture  by  means  of  elastic 
bougies,  introduced  at  intervals  of  two  or  three  days.  These  instru- 
ments should  be  softened  by  being  placed  in  warm  water  for  a  few 
minutes  before  they  are  used.  The  mechanism  of  introduction  is  the 
same  as  for  the  bulbous  bougies  just  described.  An  extra  long  whale- 
bone bougie,  after  the  pattern  of  Bank's  dilating  urethral  filiform  bou- 
gie, will  prove  of  service  in  strictures  of  such  small  caliber  that  the 
ordinary  oesophageal  bougie  can  not  be  introduced. 

Internal  oesophagotomy  is  a  justifiable  procedure  in  cases  of  organic 
stricture  which  will  not  yield  to  careful  and  persistent  efforts  at  dilata- 
tion.    In  its  performance,  the  oesophagotome  of  Prof.  Sands  (Fig.  527) 


should  be  preferred.  As  described  by  this  surgeon,*  the  shank  of  the 
instrument,  which  is  fifteen  inches  and  a  half  in  length  and  four  milli- 
metres in  diameter,  is  a  flexible  tube,  made  of  narrow,  spii'al  steel  plate, 
secured  within  by  two  pieces  of  fine  wire,  in  order  to  prevent  stretching 
or  separation  of  the  spiral  coil.  The  instrument  is  provided  with  a  vari- 
able number  of  steel  bulbs,  each  bulb  being  furnished  with  a  correspond- 
ing knife-blade.  The  bulb  is  firmly  fastened  by  a  screw  to  the  distal  end 
of  the  shank,  and  the  knife  is  attached  to  an  inner  flexible  steel  rod,  ma- 
nipulated by  a  thumb-screw  at  the  proximal  end  of  the  instrument.  By 
turning  this  screw,  the  knife  is  drawn  out  from  its  concealed  position 
within  the  bulb,  the  back  of  the  blade  sliding  over  a  firm  inclined  plane. 

*  "  New  York  Medical  Jouraal,"  February,  1884. 


510  A  TEXT-BOOK   ON  SURGERY. 

An  index  on  a  dial-i^late  indicates  the  amount  of  projection  of  the  blade, 
the  maximum  being  two  millimetres  and  a  half.  A  small  sliding  ring  on 
the  spiral  tube  is  used  to  indicate  the  distance  of  the  stricture  from  the 
incisor  teeth.  The  bulb  being  conical,  the  operator  can  readily  perceive 
when  it  comes  in  contact  with  the  stricture,  before  he  projects  the  blade. 
In  operating,  a  bulb  must  be  employed  which  exactly  fits  the  stricture  ; 
the  depth  of  the  incision  will  then  just  equal  the  distance  to  which  the 
blade  is  projected  by  the  action  of  the  screw  in  the  handle.  The  bulb  is 
introduced  beyond  the  stricture,  and  the  instrument  withdrawn  until  the 
shoulder  of  the  bulb  indicates  that  it  is  in  contact  with  the  inferior  or 
gastric  border  of  the  stricture.  It  is  then  turned  so  that  the  knife  is  pos- 
terior, the  screw  in  the  handle  which  projects  the  blade  is  turned  to  the 
required  extent,  and  the  constricting  band  divided  by  pulling  the  instru- 
ment outward  until  resistance  ceases.  The  blade  is  then  concealed  and 
the  oesophagotome  withdrawn.  The  dilating  bougies  may  be  introduced 
at  once,  or  this  may  be  postponed  for  twenty-four  hours.  The  danger 
to  be  guarded  against  is  an  incision  through  the  wall  of  the  cesophagus. 
With  the  instrument  of  Prof.  Sands  this  is  scarcely  possible,  especially 
when  the  smaller  bulbs  are  used,  since  the  greatest  projection  of  the  blade 
is  only  a  little  more  than  one  twelfth  of  an  inch. 

When  the  occlusion  is  so  complete  that  the  oesophagotome  can  not 
be  employed,  or  if  for  any  reason  this  method  of  procedure  is  contra- 
indicated  and  inanition  is  threatened,  the  operation  of  gastrostomy  is 
imperative.  It  is  not  only  to  be  commended  in  permanent  occlusion  of 
the  oesophagus  from  stricture,  a  diverticulum,  or  neoplasm,  but  in  those 
cases  in  which  extensive  inflammation  has  resulted  from  the  ingestion 
of  corrosive  substances.  In  this  last  condition  the  operation  is  intended 
to  keep  the  organ  at  rest  during  the  process  of  repair,  in  which  nothing 
but  water  is  passed  through  the  oesophagus. 

Operation. — Beginning  near  the  xiphoid  appendix,  an  incision  four 
inches  in  length  is  made,  parallel  with  and  from  one  half  to  one  inch  dis- 
tant from  the  costal  cartilages  of  the  left  side.  Strict  antisepsis  should  be 
employed,  and  all  bleeding  thoroughly  stopped  before  the  parietal  layer 
of  the  peritonpeum  is  divided.  When  this  is  done  the  index-finger  should 
be  introduced  and  the  stomach  sought  for.  If  the  obstruction  to  the 
oesophagus  is  of  long  standing,  the  organ  will  be  found  contracted  and 
much  smaller  than  normal.  When  the  anterior  wall  is  made  out,  it 
should  be  seized  with  a  forceps  or  tenaculum,  drawn  up  to  the  wound  in 
the  abdomen,  and  held  in  this  position  by  an  assistant.  The  wound  in 
the  abdominal  wall  should  now  be  closed  from  each  end,  leaving  an  open- 
ing from  one  and  a  half  to  two  inches  in  length.  The  sutures  should  be 
of  silk,  and  should  pass  through  the  integument  and  the  parietal  reflec- 
tion of  the  peritonfBum  wherever  the  serous  membrane  has  been  divided.. 

The  anterior  wall  of  the  stomach  is  now  secured  to  the  margins  of 
the  wound  in  the  following  manner :  Fine  sutures  of  iron-dyed  silk  are 
carried  at  intervals  of  from  one  eighth  to  one  quarter  of  an  inch  through 
the  integument  at  a  like  distance  from  the  edge  of  the  incision,  passing 
through  the  parietal  XDeritonaeum  and  into  the  wall  of  the  stomach,  be- 


(ESOPHAGUS.  511 

tween  tlie  muscular  and  peritoneal  layers  of  this  organ.  The  needle 
should  run  beneath  the  peritoneal  layer  of  the  stomach  for  about  one 
eighth  of  an  inch.  These  sutures  are  carried  entirely  around  the  ellip- 
tical opening,  in  this  way  uniting  the  peritoneal  layer  of  the  stomach 
with  that  of  the  abdominal  wall  and  the  integument.  A  separate  row  of 
sutures  stitching  the  edges  of  the  parietal  peritonfeum  to  that  covering 
the  stomach  is  preferred  by  some  operators.  It  is  best  not  to  open  into 
the  stomach  until  after  the  expiration  of  from  thirty-six  to  forty-eight 
hours,  by  which  time  union  ^^ill  have  occurred  between  the  contiguous 
layers  of  peritonaeum,  and  the  danger  of  infiltration  into  the  cavity  of 
the  abdomen  avoided.  If  the  necessity  for  nourishment  is  extreme,  and 
rectal  alimentation  can  not  be  relied  upon  to  sustain  the  patient,  a  quan- 
tity of  mUk  or  liquid  food  may  be  injected  by  means  of  a  medium-sized 
aspirator-needle  passed  through  the  anterior  wall  of  the  stomach.  When 
the  incision  is  made  it  should  be  fi-om  three  quarters  to  an  inch  in  length. 
An  hour-glass-shaped  hard  rubber  nipple,  with  a  lumen  of  at  least  one 
third  of  an  inch,  should  be  inserted.  A  cork  fitted  to  this  will  prevent 
regurgitation  ;  or  a  rubber  tube  may  be  substituted. 

Liquid  or  semi-solid  articles  of  food  may  be  introduced  directly  into 
the  stomach,  or,  as  practiced  in  the  remarkable  case  of  Dr.  L.  L.  Staton, 
of  Xorth  Carolina,  the  food  may  be  masticated  and  thus  submitted  to 
the  action  of  the  saliva,  and  may  then  be  forced  from  the  mouth  into 
the  stomach  through  a  tube. 

New  Formations. — EpitTielioma.  is  the  most  common  neoplasm  met 
with  in  the  oesophagus.  Colloid  and  medullary  cancer  and  sarcoma,  are 
rare  in  this  organ.  Cancer  occurs  usually  between  the  thiity-fifth  and 
sixty-fifth  year  of  life.  The  favorite  location  is  near  the  diaphragm. 
The  symptoms  of  malignant  growth  are  chiefly  those  due  to  obstruction 
and  the  development  of  the  cancerous  cachexia. 

IST on-malignant  neoplasms  are  slower  in  development,  and,  beyond  the 
dysphagia  they  may  produce,  do  not  afi'ect  the  general  condition  of  the 
patient. 

Treatment. — Malignant  new  growths  of  the  oesophagus  always  justify 
a  grave  prognosis,  especially  so  when  situated  in  the  lower  portions  of 
this  organ.  Beyond  palliative  treatment  by  dilatation  with  bougies,  or 
gastrotomy  after  deglutition  is  seriously  impaired  or  impossible,  nothing 
can  be  done.  Xon-malignant  neoplasms  are  also  not  amenable  to  surgi- 
cal interference  when  situated  below  the  level  of  the  upper  border  of  the 
sternum.  When  the  upper  portion  of  the  oesophagus  is  involved,  opera- 
tion is  iudicated,  not  only  to  relieve  dysphagia,  but  in  the  efl'ort  to  re- 
move the  disease. 

(EsopTiagectomy,  or  exsection  of  a  portion  of  this  organ,  may  occa- 
sionally be  justified  in  the  removal  of  a  malignant  growth  of  limited 
extent  and  situated  in  the  upper  portion  of  the  tube.  The  probability 
that,  before  the  character  of  the  neoplasm  is  discovered,  infiltration  of 
the  neighboring  tissues  will  have  occurred,  almost  precludes  a  favorable 
result,  and  is  therefore  a  strong  argument  against  the  propriety  of  the 
operation. 


512  A  TEXT-BOOK   ON  SURGERY. 

Diverticula,  or  pouclies  communicating  with  tlie  cavity  of  the  oesoph- 
agus, are  occasionally  met  with.  They  may  be  congenital,  but  are  more 
frequently  acquired.  They  communicate  with  the  oesophagus  usiially  on 
its  posterior  wall.  Cervical  oesophageal  diverticula  open  into  the  main 
tube  at  the  junction  of  the  oesophagus  with  the  pharynx,  whence  the 
pouch  may  extend  between  the  vertebral  column  and  the  oesophagus 
as  far  down  as  the  bifurcation  of  the  trachea.  Thoracic  oesophageal 
diverticula  occur  most  frequently  opposite  the  origin  of  the  bronchi. 

The  causes  of  these  abnormal  pouches  are  various.  As  stated,  they 
may  be  the  result  of  a  failure  in  normal  development.  A  stricture  of 
the  oesophagus  may  lead  to  a  dilatation  and  pouching  of  this  organ  in 
that  portion  immediately  above  the  seat  of  constriction.  Degeneration 
of  the  muscular  libers  of  the  tube  in  a  limited  area  may  lead  to  a  hernia 
of  the  mucous  membrane,  in  which,  by  the  impaction  of  ingested  matter, 
a  diverticulum  is  formed.  Ulceration  of  the  lining  membrane  at  any 
point,  and  from  any  cause,  may  lead  to  the  development  of  a  sac  or 
pouch  by  the  infiltration  of  ingesta  behind  the  mucous  membrane.* 

The  diagnosis  of  these  diverticula  is  made  with  great  ditBculty,  and 
little  hope  of  relief  is  offered,  even  when  the  character  of  the  lesion  is 
recognized. 

The  presence  of  the  tumor  is  indicated  by  dysphagia,  and  this  symp- 
tom may  vary  in  severity  with  the  act  of  deglutition  which  carries  food 
into  the  pouch.  Dyspnoea  may  be  present  as  the  result  of  pressure 
upon  the  trachea  and  bronchi,  and  phonation  may  be  interfered  with  if 
the  pneumogastric  or  recurrent  laryngeal  nerves  are  involved. 

The  treatment  is  chiefly  palliative,  and  consists  in  the  use  of  liquid 
diet. 

Fistula  of  the  oesophagus  may  occur  as  a  result  of  a  penetrating 
wound,  or  from  an  abscess  or  ulceration  which  destroys  a  portion  of  the 
oesophageal  wall.  A  few  instances  of  supposed  congenital  fistula  have 
been  reported. 

The  diagnosis  will  depend  upon  the  passage  of  ingested  matter 
through  the  outer  opening,  or  the  successful  introduction  of  a  probe 
from  without. 

The  treatment  is  surgical,  and  on  the  same  principle  as  applied  to  all 
fistulous  tracks  ;  they  should  be  laid  open  by  incision,  packed  to  arrest 
bleeding,  and  afterward  allowed  to  close  by  granulation.  Or,  as  in  the 
recent  procedure  for  the  relief  of  fistula  in  ano,  the  lining  membrane  of 
the  fistula  may  be  dissected  aAvay  and  the  wound  closed  throughout  with 
catgut  sutures. 

*  Rokitansky  has  advanced  the  theory  that  thoracic  diverticula  result  from  atrophy  of  the 
bronchial  lymphatic  glands,  which  are  situated  on  the  anterior  and  lateral  aspects  of  the 
ffisophagus. 


CHAPTER  XVI. 


Mammary  Oland — Congenital  Defects. — One  or  both  of  these  organs 
may  be  absent ;  one  may  develop  fully  while  the  other  remains  in  its 
primitive  condition  ;  there  may  be  three,  four,  or  five,  the  supernu- 
merary glands  being  placed  upon  the  back,  abdomen,  axilla,  or  thigh. 
The  nipple  may  be  absent  or  retracted,  and  may  be  bifid  or  multiple,  as 
many  as  a  half-dozen  occurring  within  the  limit  of  the  areola. 

The  author  presented  to  the  New  York  Surgical  Society  a  case  in 
which  a  supernumerary  gland  was  situated  in  the  axilla.  The  develop- 
ment of  this  organ  simultaneously  with  the  normal  breasts  produced 
great  pain  by  pressure  upon  the  branches  of  the  axillary  plexus.  Relief 
followed  extirpation  of  the  abnormal  gland. 

Inflammation  of  the  nipple  is  usually  traumatic,  occurring  at  the 
early  period  of  lactation,  and  being  caused  by  pressure  from  the  gums 
of  the  infant.  It  may  also  be  involved  in  the  extension  of  a  mammitis 
along  the  galactiferous  ducts. 

The  first  indication  in  treatment  is  to  give  the  organ  rest.  A  rubber 
shield  may  be  used  to  prevent  injury  while  nursing,  or  the  child  kept 
away  from  the  breast,  the  distention  of  the  gland  being  relieved  by  arti- 
ficial means.  Poultices  of  flax-seed  or  other  emollients  should  be  applied 
during  the  acute  inflammatory  process. 

Abscess  of  the  nipple  and  the  contiguous  skin  and  subcutaneous  tis- 
sue is  an  occasional  sequence  of  inflammation  of  the  nipple. 

The  treatment  is  evacuation  of  the  pus  by  one  or  more  incisions  made 
in  the  axis  of  the  efferent  ducts. 

Eczema,  or  fl,s sure  of  the  nipple,  is  of  frequent  occurrence  during  lac- 
tation. It  is  always  annoying,  and  at  times  causes  severe  pain.  Every 
source  of  irritation  should  be  removed.  If  the  integument  is  inflamed, 
poultices  should  be  applied,  and,  after  the  acute  inflammation  subsides, 
the  closure  of  the  fissures  may  be  hastened  by  the  local  use  of  glycerite 
of  tannin  or  other  astringent.  Chronic  inflammatory  processes  of  the 
nipple  which  are  intractable,  resisting  all  constitutional  and  local  reme- 
dies, demand  free  incision  and  ablation  of  the  diseased  area. 

Epithelioma  is  the  most  frequent  form  of  malignant  neoplasm  of  the 
nipple.     The  treatment  is  free  excision. 

Papillovia,  fibroma,  angioma,  cysts,  etc.,  may  occur  in  this  organ, 
and  should  be  removed  by  the  knife  as  soon  as  discovered. 


514  A   TEXT-BOOK  ON   SUKGERY. 

Mastitis. — Inflammation  of  the  breast  may  be  acute  or  chronic, 
traumatic  or  idiopathic.  A  single  lobule  or  subdivision  of  the  gland  or 
the  entire  organ  may  be  involved.  In  the  more  severe  forms  of  inflam- 
mation the  process  may  extend  along  the  ducts  to  the  nipple  and  back- 
w^ard  into  the  submammary  tissues. 

TraumaMc  mastitis  is  usually. circumscribed,  the  integument  and  sub- 
cutaneous areolar  tissue  being  also  involved.  The  deeper  tissues  escape 
unless  great  and  unusual  violence  has  been  inflicted. 

IdiopatJiic  mastitis  is  almost  always  connected  with  lactation,  occur- 
ring usually  during  the  first  few  weeks  after  parturition.  In  rare  cases 
it  occurs  at  intervals  in  non-pregnant  females,  the  symptoms  of  this  dis- 
order being  associated  periodically  with  the  menstrual  function.  Mas- 
titis is  also  a  symptom  of  parotitis  or  ^' mumps. ''^ 

The  milder  forms  which  occur  during  lactation  are  little  more  than 
exaggerations  of  the  normal  functions  of  this  organ,  while  the  more 
typical  pathological  process,  commencing  in  the  hypersemia  of  the  secre- 
tory apparatus,  is  exaggerated  by  obstruction  to  the  escape  of  the  milk 
through  the  galactiferous  ducts.  This  obstruction  may  occur  at  any  por- 
tion of  the  efferent  ducts,  although  the  occlusion  is  usually  situated  in 
or  near  the  nipple.  Distention  of  the  duct  and  its  subdivisions  leading 
back  to  the  acini  follows,  and  inflammation  ensues  in  the  entii-e  limit  of 
obstruction. 

Symptoms. — The  first  indications  of  inflammation  of  the  mammary 
gland  are  pain  and  localized  indixration.  The  pain  is  constant,  and 
usually  severe  in  character,  and  may  extend  along  the  ribs  to  the  axilla. 
The  induration  is  usually  well  defined,  and  may  consist  of  one  or  more 
nodules.  Injection  of  the  skin  is  marked  over  the  area  of  induration. 
The  temperature  is  elevated  one  or  two  degrees,  the  pulse  increased  in 
frequency,  and  a  well-pronounced  chill  or  a  series  of  rigors  is  apt  to  be 
a  feature  of  the  earlier  stages  of  this  disease. 

Treatment. — As  soon  as  inflammation  is  threatened  the  breast  should 
be  supported  by  a  bandage,  or  long,  soft  towel,  or  handkerchief  thrown 
around  the  neck  and  shoulder  and  beneath  the  gland,  holding  it  in  the 
position  of  least  discomfort.  In  the  stage  of  hypereemia  the  application 
of  a  light  ice-bag,  with  limited  compression  of  the  organ,  is  advisable. 
The  nipple  should  be  kept  moistened  with  a  tuft  of  cotton  saturated 
with  vaseline  or  oil,  which  is  placed  in  position  before  the  ice-bag  is 
applied.  Careful  attention  should  be  given  to  the  frequent  evacuation 
of  the  milk.  When  the  nipple  is  inflamed,  artificial  means  should  be 
employed  to  empty  the  breast.  If  the  infiammatory  process  does  not 
yield  to  this  treatment  after  the  first  few  days,  it  should  be  abandoned 
and  warm  jjoultices  apj)lied.  It  is  important  to  recognize  the  earliest 
collection  of  pus,  and  to  relieve  it  by  aspiration  or  incision.  Indeed, 
when  the  induration  is  localized  and  well  marked,  it  is  good  practice 
to  explore  under  cocaine  with  the  large  hypodermic  needle  to  determine 
the  presence  of  suppuration.  If  no  pus  be  found,  the  puncture  does 
no  harm,  and  of  itself  often  afl'ords  relief  from  tension. 

When  abscess  exists  the  pus  should  be  freely  evacuated  by  aspira- 


THORAX.  515 

tion  or  incision.  If  the  collection  is  deep-seated,  requiring  an  incision 
through  a  considerable  area  of  gland-tissue,  aspiration  may  be  tried  and 
repeated  for  two  or  three  times.  By  the  relief  of  tension,  resolution 
may  be  induced.  When  fluctuation  is  evident,  and  only  the  integument 
intervening,  incision  is  preferable.  This  may  be  done  without  pain, 
and  offers  the  speediest  and  surest  means  of  cure.  The  incision  should 
be  parallel  with  the  direction  of  the  galactiferous  ducts.  When  the 
cavity  is  opened,  the  nozzle  of  the  irrigator  should  be  introduced  and 
the  abscess  thoroughly  washed  out  with  l-to-3000  sublimate  solution. 
Drainage  should  be  secured,  and  a  loose  dressing  applied.  The  point 
of  incision  should  be  made  in  the  lower  portion  of  the  sac,  so  that  drain- 
age may  be  free.  At  times  it  may  be  necessary  to  make  a  counter-open- 
ing. Less  frequently  abscess  may  form  in  front  of  the  glandular  tissue 
beneath  the  integument  or  between  the  capsule  of  the  gland  and  the 
thorax.  Ostitis  or  periostitis  of  the  ribs  may  be  the  cause  of  deep- 
seated  submammary  abscess. 

Hypertrophy  of  the  mammary  gland  is  a  normal  process,  usually 
occurring  at  puberty  and  during  pregnancy  and  lactation.  In  rare 
instances  there  is  an  extensive  hyperplasia  of  the  connective-tissue  ele- 
ments of  this  organ,  resulting  in  great  enlargement.  The  diagnosis  may 
be  based  upon  the  hard  character  of  the  mass,  there  being  none  of  the 
softness  and  elasticity  which  belong  to  the  normal  breast.  The  hyper- 
plasia is  general,  involving  the  entire  framework  of  the  organ,  which 
will  render  it  easy  of  differentiation  from  any  form  of  neoplasm,  for  these 
grow  from  recognized  centers  of  induration.  The  diagnosis  meets  with 
confirmation  if  the  enlargement  takes  place  after  puberty,  and  in  a  non- 
pregnant woman. 

In  the  treatment  of  this  condition  the  hyperplasia  may  be  arrested 
in  the  earlier  stages  by  well-adjusted  and  prolonged  compression.  This 
may  be  effected  by  a  thick  layer  of  absorbent  cotton  laid  over  the 
breast  and  held  firmly  down  upon  it  by  a  roUer,  applied  as  directed 
on  pages  17  and  18.  In  advanced  cases,  a  free  excision  of  the  organ  is 
demanded. 

Tumors  of  the  Breast. — New  formations  in  the  mammary  gland  are 
among  the  more  frequent  surgical  diseases.  The  microscopical  charac- 
ters of  tumors  are  elsewhere  described.  Unfortunately,  they  are  more 
frequently  malignant  than  benign.  Although  tumors  of  the  breast  occur 
chiefly  in  females,  they  are  not  uncommon  in  males.  Among  the  non- 
malignant  tumors  are  adenoma,  myxoma,  fibroma,  and  enchondroma. 
Various  forms  of  cysts  are  also  met  with,  while  syphilitic  gumma  and 
tubercular  deposits  may  occur  in  this  organ.  Carcinoma  (scirrhus,  en- 
cephaloid,  colloid,  and  epithelioma)  and  sarcoma  are  the  malignant  neo- 
plasms which  are  found  in  the  breast. 

Adenoma  of  the  mammary  gland  is  rare.  The  pathological  change, 
a  hyperplasia  of  the  glandular  tissue  proper,  is  usually  circumscribed. 
The  tumor  is  of  small  size,  freely  movable  with  the  breast,  and  does  not 
form  adhesions  with  the  capsule,  integument,  or  submammary  fascia. 
There  is  no  inflammatory  process  connected  with  its  development,  no 


516  A  TEXT-BOOK  ON  SURGERY. 

enlargement  of  the  axillary  glands,  no  dilatation  of  the  veins  of  this  re- 
gion, and  little  or  no  pain.  It  is  found  in  nursing  women  as  a  rule,  but 
may  occur  in  early  puberty  and  in  women  who  have  not  borne  children. 
It  is  not  the  rule  for  cystic  degeneration  to  take  place  in  this  neoplasm, 
although  such  cysts  may  be  met  with  in  rare  instances  as  a  result  of  de- 
generation of  the  new-formed  cells  of  the  deeper  portions  of  the  growth. 

Adenoma,  of  itself  a  benign  neoplasm,  is  thought  by  some  patholo- 
gists to  be  capable  either  of  developing  into  carcinoma,  or  of  exciting 
the  carcinomatous  change  in  the  organ.  Not  only  in  the  simple  circum- 
scribed form  of  this  neoplasm,  but  in  that  variety  sometimes  called  tubu- 
lar adenoma,  in  which  the  hyperplasia  of  the  glandular  cells  is  not  con- 
fined to  the  acini  and  terminal  ducts,  but  extends  into  and  involves  the 
galactiferous  ducts  as  far  as  the  nipple,  and  which  is  more  generally 
diffused  than  in  the  simpler  form  above  described,  it  is  admitted  that 
the  transformation  into  carcinoma  is  possible  and  at  times  rapid. 

Treatment. — The  tumor  should,  be  excised.  When  a  considerable 
portion  of  the  gland  is  involved,  the  entire  organ  should  be  extirpated 
on  account  of  the  tendency  to  recurrence  in  this  neoplasm.  If  the  tirmor 
is  small  it  may  be  removed  by  sacrificing  only  that  part  of  the  gland- 
tissue  immediately  around  it.  Upon  the  recurrence  of  the  growth,  the 
entire  breast  should  be  excised. 

Myxoma  is  very  rarely  met  with  in  the  mammary  gland.  It  may 
occur  as  a  single  nodule  and  develop  slowly  from  a  single  center,  or  it 
may  develop  from  several  centers  and  rapidly  invade  the  entire  organ. 
It  is  not  adherent  to  the  skin  until  inflammatory  adhesions  occur  pre- 
liminary to  ulceration  of  the  mass.  Infiltration  of  the  axillary  glands 
occurs  only  as  a  result  of  inflammation.     The  nipple  is  not  retracted. 

The  prognosis  is  favorable  if  the  tumor  is  discovered  early  in  its 
development,  and  if  in  the  excision  a  sufficient  portion  of  healthy  tissue 
is  removed  with  the  neoplasm.  The  treatment  is  free  excision.  The 
entire  gland  should  be  sacrificed,  and,  if  the  organ  is  wholly  involved, 
the  line  of  incision  should  be  well  out  from  the  limits  of  the  tumor  in 
the  healthy  tissues. 

Fibroma  of  the  mammary  gland  may  occur  at  any  period  of  life.  It 
is  rarer  in  the  aged  than  in  the  young,  occurring  mostly  in  persons  under 
forty,  and  occasionally  under  puberty.  This  form  of  connective-tissue 
hyperplasia  may  affect  the  entire  organ  (as  in  general  hypertrophy, 
already  described)  or  a  circumscribed  area.  A  nodular  or  circumscribed 
fibroma  is  a  hard,  dense  tumor,  freely  movable  with  the  gland,  and  may 
or  may  not  be  painful.  Shrinkage  of  the  breast  occurs  at  times  as  a 
result  of  the  cicatricial  contraction  of  the  new-formed  tissue,  and,  when 
near  the  nipple,  its  retraction  may  resemble  that  of  scirrhus.  As  a  rule, 
this  variety  of  tumor  is  of  slow  development.  Not  infrequently  it  un- 
dergoes cystic  degeneration.  The  axillary  glands  are  not  involved,  nor 
do  adhesions  occur  until  after  atrophy  of  the  gland  with  retraction  of 
the  new-formed  connective  tissue.  It  should  be  removed  by  the  same 
wide  and  free  excision  as  recommended  for  myxoma. 

Enchondroma  of  the  breast  is  very  rare.     It  is  apt  to  be  circum- 


k 


THORAX.  517 

scribed.  Calcification  has  been  observed  in  some  of  the  few  recorded 
cases  of  this  neoplasm.  Occasionally  it  is  found  with  carcinoma.  En- 
chondroma  of  the  breast  should  be  freely  excised. 

Ci/sts. — Among  the  forms  of  cystic  tumors  found  in  this  gland  are  ga- 
lactocele,  sanguineous,  dermoid,  and  hydatid  cysts,  and  the  forms  which 
occur  in  the  degeneration  of  adenoma,  fibroma,  myxoma,  and  carcinoma. 

Galactocele  is  a  cyst  caused  by  obstruction  of  the  ducts  which  con- 
vey the  milk  toward  the  nipple.  The  obstruction  is  followed  by  disten- 
tion of  the  tubes  and  acini.  Examined  with  tlie  microscope,  the  con- 
tents of  these  cysts  consist  of  epithelial  cells  in  various  stages  of  granular 
metamorphosis,  and  milk-globules. 

The  diagnosis  may  be  determined  by  aspiration.  The  treatment 
consists  in  incision  and  evacuation  of  the  contents  with  drainage  until 
the  cyst  may  be  obliterated  by  the  process  of  granulation. 

Dermoid  and  hydatid  cysts  are  exceedingly  rare  in  this  situation. 
The  diagnosis  may  be  determined  by  aspiration,  and  the  proper  treat- 
ment is  excision.  Cysts  may  occur  in  the  breast  from  the  extravasation 
of  blood  after  contusions,  or  from  the  non-traumatic  rupture  of  blood 
or  lymph  vessels.     They  heal  readily  after  incision  and  drainage. 

Tuberculosis  of  the  breast  is  rare.  The  nodules  may  be  disseminated 
generally  through  the  gland  or  beneath  the  capsule,  or  there  may  be  one 
or  more  large  collections.  They  are  hard  to  the  touch.  The  history  of 
the  case  will  aid  in  determining  the  character  of  the  lesion.  If  there  is 
no  general  dissemination  of  tubercular  matter — that  is,  if  the  disease  is 
limited  to  the  mammary  gland — this  organ  should  be  freely  excised. 

Sarcoma  of  the  breast  attacks  usually  the  young  and  middle-aged. 
It  is  rarely  general  in  its  development,  but  commences  as  a  single  nod- 
ule, more  apt  to  occupy  the  upper  portion  of  the  organ  than  the  lower, 
whence  it  invades  the  gland  and  circumjacent  structures  in  every  direc- 
tion. The  rapidity  with  which  it  grows  depends  in  part  upon  the  micro- 
scopical character  of  the  neoplasm,  and  in  part  upon  the  age  of  the  pa- 
tient. Sarcoma  develops  more  rapidly  in  the  young,  and  the  round-cell 
sarcom.a,  which  variety  is  most  frequently  met  with  in  the  breast,  is 
more  rapid  in  its  development  than  the  spindle-cell  sarcoma.  In  the 
earlier  stage  this  tumor,  though  firm  and  nodular,  is  freely  movable 
with  the  gland.  Its  growth,  however,  is  often  so  rapid  that  the  skin 
and  subcutaneous  tissues,  the  submammary  fascia,  and  the  muscles  of 
the  chest  become  involved,  the  breast  stands  out  full  and  tense,  and  be- 
comes immovable.  The  superficial  veins  are  greatly  enlarged.  As  a 
rule,  the  lymphatic  glands  of  the  axilla  are  not  involved  until  suppura- 
tion of  the  mass  induces  axillary  adenitis. 

Differentiation  between  round  and  spindle-cell  sarcoma  is  difficult 
unless  the  tumor  is  examined  with  the  microscope.  Practically,  the  dif- 
ferentiation is  not  important.  The  first  variety  is  softer  to  the  touch, 
more  rapid  in  growth,  and  is  more  vascular.  It  is  apt  to  occur  in  the 
younger  class  of  patients. 

Both  forms  of  sarcoma  tend  to  the  formation  of  cysts  within  their 
structure.     As  stated,  they  may  be  due  to  fatty  degeneration  of  the  em- 


618  A  TEXT-BOOK   ON  SURGERY. 

bryonic  elements  of  the  tumor,  or  may  result  from  caverns  of  blood  which 
have  become  cut  off  from  the  general  circulation  through  the  tumor. 

The  diagnosis  of  sarcoma  of  the  breast  depends  upon  the  age  of  the 
patient,  the  rapidity  of  its  growth,  and  the  absence  of  axillary  engorge- 
ment.    The  treatment  consists  in  free  excision. 

Carcinoma  is  by  far  the  most  common  form  of  neoplasm  met  with  in 
the  breast.  The  order  of  prevalence  of  the  four  varieties  is  scirrhus, 
encepMloid,  colloid,  and  epithelioma.  Cancer  of  the  mammary  gland 
occurs  in  rare  instances  in  males.  In  women  it  is  met  with  most  fre- 
quently in  the  period  from  the  fortietli  to  the  sixtieth  years  of  life.  It 
may  occur  later  than  this,  and  is  rarely  seen  earlier  than  the  age  of 
thirty.  Women  who  have  never  been  pregnant  are  affected,  though 
probably  not  so  liable  as  those  who  have  borne  children. 

Scirrhus  of  the  breast  appears  usually  as  at  single  hard  nodule  or 
lump,  situated  in  the  substance  of  the  gland,  movable  within  this  organ, 
but  firmly  imbedded  in  it ;  or  two  or  more  nodules  may  appear  simul- 
taneously in  different  parts  of  the  gland,  which  eventually  approach 
each  other  so  as  to  form  a  nodulated  mass.  The  growth  of  scirrhus  is, 
as  a  rule,  not  rapid  in  the  earlier  stages  of  its  development,  but,  after 
reaching  a  certain  size,  it  spreads  with  increasing  rapidity.  The  length 
of  time  which  may  elapse  between  the  commencement  of  the  neoplasm 
and  metastasis  in  the  subpectoral  and  axillary  lymphatics  varies  in  dif- 
ferent individuals."  It  is,  however,  in  general  proportionate  to  the  rapid- 
ity of  the  growth  of  the  neoplasm.  Pain,  which  is  a  symptom  of  this 
disease,  is  lancinating  in  character  rather  than  dull  and  continuous.  It 
is  usually  more  severe  in  tumors  which  develop  rapidly. 

Cancer  of  the  breast  may  assume  the  form  of  a  single  large,  rounded, 
and  nodular  mass,  or  nodules  of  various  sizes  may  develop  in  the  organ 
or  be  scattered  in  knots  or  groups  beneath  the  integument,  in  the  pec- 
toral muscles,  or  along  the  line  of  lymphatics  leading  into  the  axilla. 
If  left  unmolested,  scirrhus  soon  invades  the  tissues  around  the  breast, 
the  muscles  of  the  chest  becoming  infiltrated,  the  skin  attached  to  the 
mass,  and  the  nipple  retracted.  On  account  of  pressure  the  circulation 
in  the  most  remote  portions  of  the  invaded  gland  is  interfered  with,  and 
ulceration  ensues,  giving  rise  to  a  more  or  less  extensive  granulating  sur- 
face, from  which  there  is  a  discharge  of  a  serous-like  fluid  containing 
blood-corpuscles,  embryonic,  pus,  and  cancer  cells.  In  the  later  stages 
lymphatic  engorgement  is  more  extensive,  and  the  effects  of  compres- 
sion upon  the  thoracic  and  axillary  nerves  more  evident.  Not  infre- 
quently the  siibclavicular,  supraclavicular,  and  cervical  lymphatics  be- 
come engorged.  Pressure-symptoms  are  not  alone  confined  to  the  nerves, 
but  the  interference  with  the  return  circulation  in  the  axillary  vein  may 
produce  general  oedema  of  the  extremity. 

EncepTialoicl  cancer  of  the  breast  differs  only  in  degree  from  the 
scirrhous  variety.  It  is  softer  under  pressure,  grows  with  much  greater 
rapidity,  ulcerates  earlier  and  more  extensively,  is  more  prone  to  hfem- 
orrhages,  and  tends  to  a  more  rapidly  fatal  termination.  It  is  more  apt 
to  recur  after  removal. 


THORAX.  519 

Epithelioma  of  the  breast  is  rare.  It  commences  in  or  near  the  nip- 
ple, and  may  extend  along  the  epithelial  lining  of  the  lactiferous  ducts, 
or  spread  along  the  integument  of  the  areola.  Although  ulceration 
begins  earlier,  its  progress  is  slower  and  less  painful  than  in  either  of 
the  forms  of  cancer  just  given,  which  attack  the  deeper  structures  of 
the  gland.  If  not  extirpated,  the  entire  gland  may  be  infiltrated,  metas- 
tasis occurs,  and  death  follows  from  general  exhaustion. 

Prognosis  and  Treatment. — The  prognosis  of  cancer  of  the  breast  is 
always  grave,  the  gravity  varying  with  the  character  of  the  neoplasm, 
the  general  condition  of  the  patient,  and  the  length  of  time  the  tumor 
has  existed  before  excision.  Left  without  surgical  interference,  a  fatal 
termination  is  reached  usually  within  from  one  to'  two  years  after  the 
appearance  of  the  disease.  Encephaloid  is  most  rapidly  fatal,  scirrhous 
next  in  order,  and  epithelioma  last.  Death  ensues  from  exhaustion 
caused  by  suppuration,  pain,  anorexia,  and  infilti'ation  of  the  various 
organs  by  metastasis.  In  isolated  cases  scirrhus  of  the  breast  reaches  a 
certain  point  and  remains  stationary  for  a  number  of  years  before  again 
enlarging  and  producing  a  fatal  issue. 

With  the  operation  as  performed  in  modern  practice,  the  prognosis 
is  much  more  favorable.  This  practice  implies  early  recognition  of  the 
presence  and  character  of  the  neoplasm,  immediate  and  wide  extirpation 
of  the  invaded  organ,  and  a  careful  dissection  of  all  metastatic  foci  in 
the  glands  of  the  axillary  plexus.  As  to  the  selection  of  cases  in  which 
operation  is  justifiable,  it  may  be  admitted  that  interference  is  called 
for  in  all  cases  in  which  the  lymphatic  engorgement  has  not  extended 
beyond  the  axillary  region,  and  in  which  the  invasion  of  the  pectoral 
and  thoracic  muscles  is  not  so  deep  or  extensive  that  a  clean  excision  is 
possible  without  opening  into  the  thorax.  Even  when  metastasis  of  the 
cervical  lymphatics  has  occurred,  relief  will  be  gained  in  those  instances 
in  which  ulceration  is  taking  place  ;  but,  in  these  cases,  the  palliative 
operation  should  not  include  invasion  of  the  axilla.  It  is  well  to  bear 
in  mind  that  a  simple  non-malignant  enlargement  of  the  glands  may 
occur  before  true  metastasis  has  taken  place. 

It  should  be  the  practice  in  all  cases  of  cancer  of  the  mammary  gland 
to  open  into  the  axilla  in  order  to  be  sure  of  the  condition  of  the  glands, 
for  these  organs  may  be  the  seat  of  cancerous  infiltration  which  can  not 
be  recognized  without  incision. 

As  to  treatment,  the  following  line  of  practice  should  be  ado^oted : 

A  tumor  of  tJie  breast  occurring  in  either  sex  after  the  thirtieth  year 
of  life  should  he  excised  as  soon  as  discovered.  The  contraindications 
to  this  procedure  are :  (1)  a  condition  of  prostration  so  extreme  that  a 
surgical  operation  would  involve  great  and  unusual  risk  to  life  ;  (2)  me- 
tastasis to  such  an  extent  that  complete  removal  of  the  neoplasm  is  im- 
possible. 

The  incision  should  be  well  away  from  the  limit  of  the  tumor  in  the 
healtJiy  tissues.  When  only  a  small  portion  of  the  organ  is  involved,  it 
is  advisable  to  extirpate  the  entire  gland.  When  the  patient  is  under 
thirty  years  of  age,  and  when  the  tumor  is  thought  to  be  benign  in  char- 


520  A  TEXT-BOOK   ON   SURGERY. 

acter,  the  less  radical  operation  of  enucleation  of  the  neoplasm  may  be 
undertaken.  Any  new  formation  so  removed  should  be  carefully  exam- 
ined, and,  if  found  to  be  malignant,  a  wider  incision  should  be  made, 
either  at  the  first  indication  of  recurrence-,  or  preferably  at  once. 

Operation. — The  patient  is  placed  upon  the  table  with  the  chest 
slightly  elevated,  the  breast  and  axilla  of  the  affected  side  near  the 
edge.  The  arm,  intrusted  to  an  assistant,  should  be  held  at  a  right 
angle  to  the  body,  and  the  head  directed  to  the  opposite  side.  The 
integument  of  the  axilla  and  within  the  field  of  operation  should  be 
shaved,  washed  with  soap  and  warm  water,  afterward  with  ether,  and 
finally  with  l-to-2000  sublimate  solution.  The  diseased  organ  should  be 
handled  as  gently  as  possible.  Sublimate  towels  should  be  laid  over  the 
exposed  surface,  leaving  only  the  part  to  be  removed  in  sight. 

The  operator  now  carefully  outlines  the  tumor,  since  it  is  essential 
that  the  incision  should  be  from  one  to  two  inches  outside  of  the  limit 
of  induration.  On  this  line  the  skin  and  subcutaneous  tissues  should 
be  divided  directly  down  to  the  muscles.  The  fascial  covering  of  the 
thoracic  muscles  should  be  dissected  up  with  the  gland.  If  the  infiltra- 
tion has  involved  the  deeper  portions  of  the  organ,  the  pectoral  muscles 
within  the  line  of  incision  should  be  dissected  out,  leaving  nothing  but 
the  ribs  and  intercostal  muscles.  All  vessels  should  be  secured  and  tied 
with  catgut  as  fast  as  divided.  Oozing  may  be  arrested  by  pressing 
sponges  or  sublimate  towels  into  the  wound  as  the  operation  proceeds. 

The  dissection  should  be  made  and  the  mass  lifted  from  the  sternum 
toward  the  axilla.  In  this  way  the  larger  vessels  (the  long  thoracic 
artery  and  branches)  are  not  divided  until  the  incision,  which  completely 
severs  the  tumor,  is  being  made. 

All  haemorrhage  in  the  wound  being  arrested,  and  this  filled  with 
warm  sublimate  towels  to  prevent  oozing,  the  dissection  should  be  con- 
tinued into  the  axilla.  During  this,  the  most  difficult  j^art  of  the  opera- 
tion, the  arm  should  be  held  immovably  at  an  angle  of  90°  to  the  axis  of 
the  spine.  From  the  end  of  the  elliptical  wound  nearest  the  axilla,  an 
incision  is  made  along  and  below  the  border  of  the  pectoralis  major 
muscle,  extending  as  far  as  the  arm.  The  integument  below  this  incision 
should  be  dissected  up  from  the  underlying  areolar  tissue  down  to  the 
posterior  fold  of  the  axilla,  blunt  retractors  placed  above  and  below, 
and  the  edges  of  the  wound  separated  as  widely  as  possible.  It  is  ad- 
visable to  remove  the  adipose  tissue  which  fills  in  this  space  along  with 
the  enlarged  glands.  The  chief  danger  is  the  wounding  of  the  axillary 
vein  or  one  of  its  branches  so  close  to  the  main  trunk  that  air  may  be 
admitted  or  the  ligature  have  to  be  applied  to  the  axillary  vein.  If  the 
dissection  is  made  with  blunt  scissors  curved  on  the  flat,  keeping  the  con- 
vex surface  nearest  the  vein,  and,  if  the  vessel  is  approached  from  the 
scapular  border,  this  danger  may  be  avoided.  In  this  region  the  sub- 
scapular vein  is  easily  recognized,  and  may  be  followed  toward  the  large 
trunk.  In  the  lower  portion  of  the  axiUa  the  brachial  fascia  protects 
the  vein.  If  the  enlarged  glands  extend  high  up  in  the  axilla,  the  pec- 
toralis major  and  minor  should  be  cut  across   and   a  clean  dissection 


THORAX.  521 

made  as  high  as  the  clavicle  if  necessary.  When  a  hard  gland  is  found 
lying  directly  upon  the  sheath  of  the  vein,  it  may  be  removed  by  the 
thumb  and  finger-nail.  When  working  close  to  the  axillary  vein  and 
artery,  all  hsmoiThage  may  be  avoided  by  applj-ing  forceps  on  each  side 
of  the  track  of  the  incision  before  the  scissors  are  used,  and  immedi- 
ately tying  the  tissues  grasped  with  catgut.  Occasionally  the  vein  will 
be  found  so  studded  with  metastatic  foci  that  removal  without  injury  to 
this  vessel's  wall  is  impossible.  When  this  condition  exists,  either  the 
operation  wid  have  to  be  abandoned  or  the  vein  and  its  branches  tied 
above  and  below  the  neoplasm,  and  the  intermediate  portion  exsected. 

In  one  of  my  cases  this  operation  was  performed.  The  axillary  vein 
was  tied  near  the  clavicle,  and  the  brachial  just  below  the  tendon  of 
the  pectoralis  major,  and  double  ligatures  to  all  intervening  branches. 
The  neoplasm  had  not  recurred  two  years  after  the  operation.  The 
venous  cii-culation  was  well  established  through  the  cephalic  vein.  The 
patient  was  in  excellent  health.  When  the  operation  is  completed,  a 
drainage-hole  should  be  made  from  the  deepest  portion  of  the  wound 
(estimating  this  from  the  position  the  patient  is  to  assume  after  the 
operation)  by  carrying  the  tip  of  a  closed  dressing -forceps  through  the 
tissues  until  the  skin  along  the  axillary  border  of  the  scapula  is  lifted 
by  the  instrument.  This  should  be  incised  and  the  hole  enlarged  by 
separating  the  jaws  of  the  forceps.  A  good-sized  rubber  di-ainage-tube 
should  be  pulled  through  from  below  as  the  forceps  are  A^ithdi'awn.  As 
much  of  the  wound  is  closed  by  sutures  as  possible,  a  final  iri'igation  of 
l-to-3000  sublimate  is  made,  a  loose  dressing  placed  in  the  open  portion 
of  the  wound,  and  the  usual  dressing  of  gauze  and  borated  cotton,  and 
protective  placed  over  all. 

When  a  benign  tumor  is  to  be  enucleated  from  the  breast,  the  incision 
may  usually  be  made  along  the  crescentic  fold  at  the  lower  border  of 
this  organ,  the  gland  turned  up,  the  tumor  removed,  and  the  breast  re- 
stored to  its  former  position.  The  scar  is  concealed  in  the  natural  fold 
between  the  integument  of  the  thorax  and  the  breast. 

Abscess  of  the  thoracic  walls  usually  results  from  ostitis  of  the  clavi- 
cle, sternum,  ribs,  scapulae,  or  vertebrae,  or  enchondritis  of  the  costal 
cartilages.  If  not  incised,  they  open  spontaneously  through  the  integu- 
ment and  discharge  pus  and  at  times  particles  of  bone  and  other  de- 
tritus. Spontaneous  cure  may  occur,  although  this  is  the  exception. 
Sinuses  usually  result,  and  continue  until  the  diseased  tissues  are  ex- 
cised. The  most  common  seat  of  ostitis  is  in  the  sternum  and  the  sternal 
ends  of  the  ribs.  The  indications  in  treatment  are  to  lay  the  sinuses 
open,  carefully  following  each  to  its  terminus,  scrape  the  indurated 
lining  membrane  away  with  a  scoop,  and  remove  all  dead  bone  by 
scraping  with  the  Volkmann  spoon  or  exsection  in  mass.  Opening  into 
the  pleura  or  mediastinum  should  be  avoided.  When  the  abscess  leads 
behind  the  sternum,  as  in  a  case  which  came  under  my  care,  a  segment 
of  this  bone  should  be  removed  in  order  to  expose  and  drain  the  cavity. 
In  exsection  of  a  portion  of  one  or  more  ribs,  the  incision  should  be 
made  along  the  center  of  the  bone,  the  periosteum  lifted  with  the  ele- 


522 


A   TEXT-BOOK   ON   SURGERY. 


vator  (first  from  the  anterior  surface  and  then  from  behind),  and  the 
bone  divided  with  the  exsector  or  cutting-forceps.  All  of  these  wounds 
should  be  packed  with  sublimate  gauze. 


Fig.  528. — Portions  of  the  left  clavicle  removed  on  account  of  ostitis. 


Exsection  of  the  clavicle  may  be  demanded  in  ostitis  of  this  bone. 
In  a  case  operated  upon  by  myself  for  necrosis  resulting  from  a  disloca- 
tion at  the  sternal  end,  the  incision 
extended  the  entire  length  of  the 
bone,  and  the  excision  was  subpe- 
riosteal throughout.  A  new  and 
strong  clavicle  formed,  with  perfect 
motion  at  the  sternal  and  acromial 
articulations.  The  shortening  was  a 
little  less  than  one  inch.  Six  years 
after  the  operation  the  function  of 
the  injured  side  is  perfect  (Figs. 
528,  529). 

Empyema. — Pus  may  collect  in 
the  pleural  sac  as  a  circumscribed 
abscess,  or  exist  in  the  general  cav- 
ity of  the  pleura. 

The  diagnosis  may  be  determined 
from  the  elevation  of  temperature 
usually  present,  by  dullness  on  per- 
cussion over  the  fluid,  and  by  aspi- 
ration, using  the  smaller  needles. 
The  treatment  consists  in  evacuation 
of  the  purulent  contents  with  the  as- 
pirator, or  by  incision.  If  the  symp- 
toms of  septic  absorption  are  not  urgent,  aspiration  may  be  tried  and 
repeated  at  intervals  until  recovery  ensues,  or  until  a  failure  of  this 
method  is  demonstrated.  The  contents  of  the  pleural  cavity  should  not 
be  too  rapidly  evacuated.  Fatal  syncope  has  occurred  in  several  in- 
stances during  this  operation.  Incision  should  be  done  in  all  urgent 
cases,  and  in  those  instances  in  which  aspiration  fails.  The  object  of 
this  operation  is  to  drain  the  cavity  of  the  abscess  at  its  most  dependent 
portion.  An  effort  should  be  made  to  determine  the  lowest  point  by  the 
introduction  of  the  needle  in  several  of  the  intercostal  spaces.  The 
opening  should  be  made  about  opposite  the  center  of  the  rib,  preferably 
a  little  posterior  to  the  middle.  The  incision  should  be  in  the  intercostal 
space,  half-way  between  the  ribs.  When  the  costal  pleura  is  divided,  it 
will  be  indicated  by  the  escape  of  pus  and  the  entrance  of  air.     Partial 


Fjg.  529. — The  author's  case,  in  which  a  new  clav- 
icle was  formed  after  subperiosteal  excision. 


WOUNDS   OF  THE   CHEST.  523 

collapse  of  the  lung  of  the  affected  side  follows.  As  soon  as  the  incision 
is  completed,  the  finger  of  the  operator  should  be  introduced  in  order  to 
determine  if  the  opening  is  near  the  bottom  of  the  cavity.  If  not,  it  is 
usually  advisable  to  make  a  second,  or  counter  opening,  on  a  lower  level. 
A  drainage-tube,  or  preferably  two  tubes,  are  carried  side  by  side  in  at 
one  opening  and  out  at  the  other,  and  secured  by  transfixion  with  safety- 
pins.  If  a  single  opening  is  made,  the  double  tube  should  always  be 
used.  The  cavity  should  now  be  washed  out  ^vith  l-to-3000  sublimate, 
and  a  dressing  applied.  Later,  a  stronger  solution  may  be  used.  I  have 
repeatedly  irrigated  with  1-to-lOOO  sublimate,  with  no  poisoning. 

If  the  ribs  are  so  close  together  that  free  drainage  can  not  be  secured, 
a  portion  of  one  rib  should  be  exsected.  The  opening  should  be  large 
enough  to  admit  the  index-finger.  It  is  usually  advisable  to  do  this, 
since  the  collapse  of  the  chest-wall  which  follows  is  exceedingly  apt  to 
occlude  partially,  if  not  completely,  the  opening  through  the  intercostal 
space.  Portions  of  several  ribs  should  be  excised  when  necessary  to 
thorough  drainage. 

Ostitis  or  other  diseases  of  the  scapula  do  not  require  especial  con- 
sideration.    Removal  of  any  portion  or  all  of  this  organ  may  be  effected. 


Wounds  of  the  Chest. 

Wounds  of  the  chest  are  divided  into  penetrating  and  non-penetrat- 
ing. A  penetrating  wound  is  one  which  opens  into  the  pleural  cavity 
or  mediastinum.  Pneumothorax,  with  hsemorrhage  into  the  pleural  sac, 
may  occur,  however,  without  an  external  opening,  as  when,  after  a  con- 
tusion of  the  chest  a  rib  is  fractured,  causing  rupture  of  the  intercostal 
artery  and  penetration  of  the  lung. 

Contused  wounds  of  the  chest  may  be  accompanied  by  fracture  of  the 
ribs,  lacerations  of  the  muscles,  or  followed  by  pleuritis  with  or  without 
either  of  the  above  complications. 

Non-penetrating  wounds  of  the  chest,  whether  incised,  lacerated,  or 
punctured,  are  treated  as  directed  for  such  lesions  in  other  parts  of  the 
body.  The  same  may  be  said  of  gunshot- wounds  which  do  not  involve 
the  bony  framework  of  the  thorax  or  pass  into  the  cavities. 

Penetrating  wounds  of  the  thorax  are  dangerous  in  proportion  to  the 
size  of  the  entering  substance,  the  direction  and  depth  of  the  track  of 
the  wound. 

Punctured  wounds,  not  involving  the  heart  and  great  vessels,  are  not 
usually  fatal,  while  death  is  apt  to  follow  even  small  lesions  of  these 
organs.  Incised  wounds  are  more  dangerous,  while  gu?is7iot-wovLnds  are 
still  graver  lesions. 

Passing  in  any  direction  into  or  through  the  mediastinum,  a  gunshot- 
wound  is  apt  to  inflict  fatal  violence.  In  the  lungs  and  pleurae  the  prog- 
nosis is  not  so  grave,  being  proportionate  to  the  size  of  the  missile  and 
to  the  nearness  of  its  approach  to  the  great  vessels  at  the  root  of  the 
lung. 


524  A  TEXT-BOOK   ON  SURGERT. 

Again,  if  a  rib  is  fractured  at  the  point  of  entrance,  the  gravity  of 
the  prognosis  is  increased  from  the  lodgment  of  particles  of  bone  driven 
into  the  lung.  Wounds  produced  by  missiles  of  small  caliber,  not  fatal 
within  a  few  hours,  are  apt  to  end  in  recovery. 

Diagnosis. — Penetrating  wounds  of  the  chest,  involving  the  lung,  are 
accompanied  almost  always  by  bleeding  from  the  mouth,  dyspnoea,  and 
by  the  jDassage  of  air  in  and  out  through  the  wound  ^vith  each  respira- 
tory act.  The  dyspnoea  is  due  to  blood  in  the  bronchial  tubes  and 
trachea,  and  often  to  partial  coUapse  of  the  lung,  which  is  caused  by  the 
entrance  of  air  through  the  wall  of  the  thorax. 

The  admission  of  air  to  the  i)leural  sac  does  not,  however,  always 
follow  a  penetrating  wound,  on  account  of  its  small  size  or  the  valvular 
arrangement  of  the  tissues  through  which  it  passes. 

Shock  is  usually  i)rofound  if  the  lung  is  wounded.  A  wound  of  en- 
trance and  exit,  with  the  pleura  and  lung  directly  between,  indicates 
lesion  of  these  organs.  Occasionally,  however,  a  ball  strikes  against  a  rib, 
is  deflected,  and  sweeps  around  the  chest  beneath  the  skin  and  makes  its 
exit  at  a  remote  point  without  entering  the  pleural  cavity. 

Treatment.— The  arrest  of  hsemorrhage  is  the  immediate  indication. 
This  may  be  hastened  by  deligation  of  the  extremities,  already  described 
on  page  74. 

Any  bleeding  from  the  vessels  of  the  thoracic  wall  should  be  arrested 
by  the  ligature.  Foreign  bodies,  fragments  of  bone,  etc.,  near  the  wound 
of  entrance  or  exit,  should  be  removed.  When  hernia  of  the  lung  occurs, 
if  seen  before  strangulation  has  taken  place,  it  should  be  irrigated  with 
l-to-5000  sublimate  solution  and  reduced.  If  gangrenous,  the  protrading 
mass  should  be  tied  with  the  elastic  ligature  and  the  dead  portion  re- 
moved. 

Uncomplicated  wounds  of  small  size  should  be  closed  at  once  by  an 
iodoform  and  sublimate  gauze  dressing,  well  applied.  If  symptoms  of 
empyema  foUow,  an  ojiening  may  be  made  for  drainage,  provided  that 
the  presence  of  pus  is  demonstrated  by  the  aspirator. 

In  complicated  wounds,  where  the  opening  is  large,  or  where  frag- 
ments of  bone,  clothing,  or  any  foreign  substance  has  been  driven  into 
the  pleura  and  lung,  it  should  be  kept  open  for  drainage  and  treated  by 
irrigation,  as  dir-ected  for  empyema. 

In  wounds  of  the  heart  the  right  auricle  and  ventricle  are  most  fre- 
quently injured.  Punctured  wounds  are  less  apt  to  prove  fatal  than 
those  produced  by  gun-missiles.  Fischer  has  collected  four  hundred  and 
fifty- two  cases  of  wounds  of  the  heart,  with  seventy-two  recoveries.* 

The  symptoms  of  injury  to  the  heart  are  those  of  profound  shock. 
The  pulse  is  irregular,  and,  if  there  is  hfemorrhage  into  the  pericardium 
and  mediastinum,  symptoms  of  pressure  on  the  heart-muscle  are  soon 
evident. 

The  means  employed  to  arrest  internal  hsemorrhage  elsewhere  may  be 
used  here.     Quiet  should  be  enforced. 

*  "  Arctiv  fur  klinische  Chirursie,"  1868. 


CHAPTER  Xyil. 


THE   ABDOMEN. 


Tlie  Stomach. — Gastrostomy*  which  operation  has  been  described  in 
the  article  on  oesophageal  stricture,  is  required  occasionally  in  th6  removal 
of  foreign  bodies  which  have  been  carried  into  the  stomach  and  can  not 
find  an  exit  through  the  pylorus  or  be  ejected  in  the  act  of  voniiting. 
Although  a  considerable  degree  of  tolerance  may  be  pi-esent,  if  the  size 
and  shape  of  the  foreign  body  are  such  that  the  probability  of  its  re- 
moval by  natural  means  is  remote,  the  stomach  should  be  opened. 

The  method  of  procedure  is  the  same  as  that  already  described.  Since 
the  oesophagus  is  patent,  the  stomach  should  be  thoroughly  washed  out 
with  warm  water  introduced  by  means  of  the  oesophageal  tube  and  the 
pump.  No  solid  food  should  be  allowed  within  twelve  hours  of  the 
incision  into  the  wall  of  this  organ.  This  double  precaution  will  pre- 
vent the  otherwise  possible  escape  of  ingested  matter  into  the  peritoneal 
cavity.  The  stomach  should  not  be  opened  until  it  has  been  securely 
stitched  to  the  edges  of  the  wound  in  the  abdominal  wall,  as  heretofore 
directed.  The  foreign  body  may  be  felt  with  the  finger  and  extracted 
with  a  pair  of  dressing-forceps.  The  opening  should  not  be  closed  at 
once,  but  allowed  to  heal  by  granulation. 

Gastrostomy  may  also  be  justifiable  in  certain  cases  of  stricture  of 
the  pylorus,  in  which  at  least  temporary  benefit  may  be  obtained,  by 
dilatation  of  the  stricture  by  the  finger  introduced  through  the  stomach, 
or  by  mechanical  means  used  in  the  same  way.  An  incision  about  five 
inches  in  length  should  be  made  from  the  apex  of  the  ensiform  cartilage 
downward  and  to  the  right,  parallel  with  and  about  one  inch  below  the 
curve  of  the  right  costal  cartilages.  On  account  of  the  over-distention  of 
the  organ,  the  pylorus  may  be  farther  to  the  right  of  the  linea  alba  than 
normal.  The  incision  in  the  abdominal  wall  should  be  free  ;  the  stomach 
drawn  into  the  wound,  and  a  longitudinal  incision  fi'om  one  to  one  and 
a  half  inch  in  extent  made  on  its  anterior  wall  near  the  pylorus.  The 
finger  should  be  introduced  gradually  and  forcibly  into  the  stricture. 
If  the  stenosis  is  so  great  that  the  finger  can  not  be  used,  the  dressing- 
forceps  or  any  dilating  instrument  may  be  substituted.     After  the  dila- 

*  The  operations  of  gastrostomy  and  gastrotomy  differ  only  in  this,  that  the  former  is 
intended  to  be  more  or  less  permanently  used  for  the  introduction  of  nourishment,  while  the 
latter  is  either  closed  at  once  or  allowed  to  close  in  a  short  time. 


526  A  TEXT-BOOK   ON    SURGERY. 

tation  is  completed  the  incision  in  the  stomach  should  be  closed  by  Lem- 
bert's  suture.  If  the  operation  shall  have  proceeded  thus  far  and  the 
pylorus  found  to  be  occluded,  or  so  nearly  closed  that  the  passage  of 
ingesta  is  impossible  and  its  dilatation  can  not  be  successfully  accom- 
plished, one  of  two  procedures  may  be  adopted :  I,  exsection  of  the 
pylorus  ;  2,  gastro-enter ostomy.  ''■ 

Exsection  of  the  pylorus  {pylorectomy)  for  malignant  disease  involves 
almost  of  necessity  a  removal  of  a  portion  of  the  lesser  end  of  the  stom- 
ach {gastrectomy)  with  the  diseased  portion  of  the  duodenum.  Even  for 
intlammatory  stricture  (contractions  after  ulcer,  etc.)  simple  pylorectomy 
is  scarcely  possible. 

The  operation  is  preceded  by  washing  out  the  stomach  with  warm 
water  once  a  day  for  several  days,  and  a  thorough  irrigation  just  before 
it  is  incised.  A  purgative  to  clear  out  the  intestinal  canal  is  scarcely 
necessary,  since,  as  a  rule,  only  liquids  pass  through  the  stricture.  The 
most  careful  antiseptic  details  should  be  carried  out.  The  center  of  the 
incision  through  the  abdominal  wall  should  be  immediately  over  the 
recognized  position  of  the  part  to  be  excised.  If  a  neoplasm  is  present, 
it  may  be  readily  located  by  palpation.  If  no  appreciable  tumor  exists, 
the  pylorus  will  be  found  just  to  the  right  of  the  median  line  about  the 
level  of  the  costal  cartilages,  curving  downward  on  the  right  side  of  the 
ensiform  appendix  (Fig.  530) ;  the  incision  should  extend  from  near  the 
appendix,  parallel  with  and  about  one  inch  from  the  border  of  the  cos- 
tal cartilages  of  the  right  side.     It  should  be  about  five  inches  in  length. 

All  haemorrhage  should  be  arrested  before  the  parietal  layer  of  the 
peritonaeum  is  incised.  When  this  is  done,  the  finger  should  be  intro- 
duced and  the  pylorus  located  by  following  along  the  anterior  smooth 
surface  of  the  stomach,  beneath  the  overlapping  free  border  of  the  liver. 
If  it  be  discovered  that  the  incision  is  not  sufficiently  free,  a  large  flat 
sponge  should  be  placed  in  the  abdomen  between  the  edges  of  the  wound 
and  the  viscera,  to  prevent  the  escape  of  blood  into  the  cavity  while  the 
opening  is  being  enlarged.  The  wound  should  be  widely  dilated,  the 
liver  and  gall-bladder  held  up  out  of  the  way  (care  being  taken  not  to 
wound  this  friable  and  vascular  organ),  and  the  parts  to  be  removed 
brought  into  view. 

Having  determined  the  extent  of  stomach  and  duodenum  to  be 
removed,  these  organs  should  be  lifted  as  far  as  possible  into  the  wound, 
and  the  omental  attachments,  on  both  curvatures,  divided  between  two 
rows  of  catgut  ligatures  as  far  as  the  line  of  excision,  and  no  farther.  As 
soon  as  the  peritoneal  attachments  are  divided,  a  flat  sponge,  which  has 
been  taken  from  a  vessel  containing  Thiersch's  solution  warm  (boracic 
acid,  grs.  iv  ;  salicylic  acid,  gr.  j ;  water,  grs.  500),  and  squeezed  fairly 
dry,  should  be  placed  under  the  parts  to  be  excised  in  order  to  prevent 
blood  or  other  matter  from  getting  into  the  peritoneal  cavity.  The  wall 
of  the  stomach  is  next  cut  through  in  a  transverse  direction,  and,  when 
a  sufficient  opening  has  been  made,  all  fluids  or  other  matter  should  be 
removed  by  small  soft  sponges  attached  to  holders.  Some  operators 
apply  a  clamp  across  the  stomach  just  above,  and  to  the  duodenum  just 


GASTRO-PYLORECTOMY. 


527 


I 


below  the  line  of  excision.  AU  hgemorrhage  should  be  arrested  as  the 
operation  proceeds.  If  a  clamp  is  not  employed,  a  silk  loop  should  be 
thrown  around  the  duodenum  to  prevent  its  slipping  downward.     When 


<!' 

T--^/    1 

U' 

^     V 

f 

\ 

'         ' '  r*" 

^-.>^     ^^ 

Fig.  530.— (After  Maclise 

•) 

the  diseased  portion  is  removed,  the  wound  in  the  stomach  should  be 
closed  from  the  lesser  curvature  downward,  until  the  opening  left  is  of 
the  same  size  as  that  in  the  divided  duodenum.     The  materials  to  be 


528  A  TEXT-BOOK   ON   SURGERY. 

used  are  fine  iron-dyed  silk,  small  needles  half-curved  and  perfectly 

round  on  section,  and  the  needle-holder. 

The  method  of  closure  is  by  the  Czerny-Leinbert  suture  (Fig.  531). 

The  first  row  are  inserted  from  the  inner  side,  the  needle  passing  only 
through  the  mucous  membrane  and  submucous  tis- 
sue, but  not  including  the  peritonseum.  The  pos- 
terior half  of  the  wound  should  be  closed  first. 
The  outer  suture,  which  is  that  of  Lembert,  passes 
beneath  the  peritoneal  covering,  practically  run- 
nins;  through  the   muscular  layer,   but  does  not 

Fig,  531.— The  Czerny-Lem-  .    °  ,        °  ,  mi  ti 

bert  suture.  The  upper  pierce  the  mucous  membrane,  ihe  needle  is  m- 
fowCT  is^CMray'^!''^'  ^'"^  troduced  on  one  side  three  sixteenths  of  an  inch 
from  the  cut  edge  of  the  viscus,  and  is  made  to 
emerge  one  sixteenth  of  an  inch  from  the  margin  (passing  about  one 
eighth  of  an  inch  beneath  the  peritoneal  coat).  It  is  then  carried  to  the 
opposite  side  and  introduced  in  the  same  manner  one  sixteenth  of  an 
inch  from  the  cut  edge  and  brought  out  one  eighth  of  an  inch  farther  on. 
This  suture  should  be  repeated  every  eighth  of  an  inch.  As  fast  as  in- 
troduced the  ends  should  be  tied  together  and  intrusted  to  an  assistant. 
The  sutures  are  not  finally  tied  until  all  are  inserted,  and  are  then 
secured  from  above  downward. 

When  the  upper  portion  of  the  aperture  in  the  stomach  is  closed,  the 
sutures  should  be  carried  from-  the  edges  of  the  remaining  aperture  across 
to  corresponding  points  upon  the  duodenum,  and,  when  the  entire  cir- 
cumference is  completed,  should  be  tied  and  cut  off  close  to  the  knot. 
After  a  careful  cleaning  of  the  peritoneal  cavity,  the  edges  of  the  peri- 
toneal layer  of  the  abdominal  wall  are  brought  together  with  catgut 
sutures,  while  silver  wire  or  strong  silk  sutures  are  carried  through  the 
integument,  muscles,  and  fascia  down  to  the  peritonseum,  and  the  wound 
closed.  The  stomach  should  be  kept  at  rest  for  the  first  day  or  two. 
An  enema  of  beef-tea  and  whisky  should  be  given  every  four  or  five 
hours.  From  two  to  four  ounces  of  the  former  to  3j-ij  of  the  latter 
may  be  administered  at  each  injection.  Crushed  ice  in  moderate  quan- 
tities may  be  given  in  the  mouth.  After  two  days,  milk  and  liquid  food 
in  small  quantities  may  be  given  by  the  mouth,  and  solid  food  by  the 
tenth  day. 

Gastro-enterostomy  is  an  operation  in  which  an  opening  is  established 
between  the  stomach  and  some  point  along  the  small  intestine,  usiially 
the  upper  portion.  On  account  of  the  position  of  the  duodenum  and  its 
relations  to  the  pancreas  and  great  mesenteric  vessels,  it  can  not  be  util- 
ized. The  nearest  loop  of  the  jejunum  should  be  selected.  In  Wolfler's  * 
operation  (Fig.  532)  the  stomach  was  opened  a  finger's  breadth  above  the 
attachment  of  the  gastro-colic  omentum  to  the  greater  curvature.  The 
incision  was  in  the  long  axis  of  the  organ,  and  measured  five  centime- 
tres (about  two  inches).     A  similar  incision  was  made  in  the  nearest  loop 

*  This  operation  was  performed  in  the  case  of  a  patient  in  whom  there  was  a  cancer  of  the 
pylorus  too  large  to  be  excised.  The  man  recovered  and  was  much  improved.  "Centralblatt 
far  Chirurgie,"  No.  45,  1881,  p.  706. 


I 


GASTRO-ENTEROSTOMY.  529 

of  small  intestine  opposite  to  tlie  mesenteric  attachment.     The  posterior 
wall  of  the  wonnd  in  the  intestine  was  first  stitched  to  the  corresponding 
edge  of  the  incision  in  the  stomach,  and  the  operation  completed  by 
uniting   the   anterior  walls.     Car- 
bolized  flat  sponges  were  placed 
beneath  the  organs  during  the  op- 
eration. 

The  incision  in  the  abdominal 
waU  in  this  procedure  may  be  the 
same  as  that  for  exsection  of  the 
pylorus^  or  a  free  longitudinal  iu- 
cision  in  the  linea  alba  may  be  em- 
ployed. 

Exsection  of  the  pylorus  is  a 
difiicult  operation,  requiring  a  most 

perfect   knowledge  of  the  anatomy       f,„  532.-W6lfler's  operation  for  gastro-enterostomy. 

of  the  parts  involved,  and  a  thor- 
ough drilling  in  the  practice  of  intestinal  suture  and  the  management  of 
intra-abdominal  wounds.  The  long  duration  of  the  operation,  together 
with  the  already  weak  condition  of  the  patient,  renders  a  fatal  termi- 
nation very  probable ;  and  if  done  for  malignant  disease,  and  recovery 
follow,  the  recurrence  of  the  neoplasm  is  almost  certain.  For  malignant 
neoplasm  it  is  scarcely  justifiable  ;  for  non-malignant  stricture  limited  in 
extent,  its  propriety  may  be  entertained. 

The  operation  of  Wolfler  {gastro-enterostomy)  is  more  simple,  requires 
less  time  in  its  execution,  and  offers  a  better  chance  of  recovery  and  pro- 
longation of  life.  With  the  time  saved  in  this  operation  (as  in  other 
cases  of  intestinal  anastomosis),  by  the  use  of  Senn's  absorbable  bone- 
plates,  or  Abbe's  catgut  rings — elsewhere  described  and  shown — the 
danger  of  a  fatal  termination  may  be  lessened.  Throi;gh  the  opening 
thus  made  the  food  acted  upon  by  the  gastric  juice  passes  into  the  small 
intestine  and  there  meets  with  the  bile,  pancreatic  and  intestinal  juices. 

As  far  as  can  be  determined  by  the  study  of  a  limited  number  of 
cases,  dilatation  of  non-malignant  stricture  of  the  pylorus  is  a  justifiable 
operation.  If  the  stenosis  recurs  within  one  or  two  years,  and  if  the 
contraction  is  limited  in  extent,  the  surgeon  should  choose  between  pylo- 
rectomy  and  gastro-enterostomy.  If  the  cause  of  the  stenosis  is  cancer, 
dilatation  can  only  produce  a  temporary  relief.  The  danger  of  the  oper- 
ation is  practically  as  great  as  in  gastro-enterostomy,  and  this  last  pro- 
cedure, if  successful,  offers  the  best  hope  of  prolonging  life  and  lessening 
suffering.  When,  as  a  result  of  pyloric  stenosis,  life  is  endangered  to 
such  an  extent  that  operative  interference  is  determined  upon,  the  ab- 
dominal wall  should  be  opened  by  the  curved  incision  above  given,  and 
a  careful  examination  made.  If  malignant  disease  is  discovered,  and  if 
from  the  size  and  ajipearance  of  the  neoplasm  infiltration  of  the  neigh- 
boring tissues  has  taken  place,  or  if  the  neoplasm  involves  the  stomach, 
necessitating  if  exsected  the  removal  of  a  portion  of  this  organ,  exsec- 
tion should  be  abandoned  and  gastro-enterostomy  performed. 

34 


530  A  TEXT-BOOK  ON  SURGERY. 

Duodenum. — Operations  upon  this  organ  must  be  chiefly  confined  to 
the  upper  portion  on  account  of  the  relations  of  the  bile  and  pancreatic 
ducts  to  the  middle  portion,  and  the  body  of  the  pancreas  and  great 
mesenteric  vessels  to  the  lower  third. 

Duodenostomy  has  been  performed  in  several  instances  for  the  relief 
of  stenosis  of  the  pylorus,  but  without  success.  The  incision  through 
the  abdominal  wall  is  the  same  as  in  pylorectomy.  The  opening  should 
be  made  in  the  upper  portion  of  the  organ,  after  adhesions  have  been 
secured  by  stitching  the  intestine  to  the  edges  of  the  wound  in  the  ab- 
dominal wall,  as  in  gastrostomy.  Digital  or  instrumental  dilatation  of 
the  stricture  is  done  through  the  fistulous  opening.  The  benefit  to  be 
derived  from  this  operation  is  less  than  that  after  gastro-enterostomy  or 
dilatation  of  the  pylorus,  and  is  fully  as  dangerous. 


Obsteuction  of  the  Alimej^taet  Cawal  below  the  Ptlortts. 

Partial  or  complete  occlusion  of  the  alimentary  canal  may  occur  from 
a  variety  of  causes,  namely :  1,  impaction  of  fecal  matter ;  2,  foreign 
bodies  ;  3,  intussusception ;  4,  volvulus  ;  5,  constriction  by  bands ;  6, 
by  adhesions ;  7,  omental  and  mesenteric  slits ;  8,  diverticula ;  9,  neo- 
plasms ;  10,  stricture  ;  11,  true  hernia. 

The  impaction  of  ingested  matter  may  occur  at  any  part  of  the  ali- 
mentary canal,  although  this  accident  occurs  in  the  great  majority  of 
cases  in  the  large  intestine.  The  coecum  and  ascending  colon  are  the 
most  common  seats  of  fecal  impaction,  the  sigmoid  flexure  next  in 
order. 

The  symptoms  upon  which  a  diagnosis  is  made  are  the  presence  of  a 
tumor  in  the  line  of  the  colon,  which  is  not  painful  on  pressure,  may  be 
molded  by  firm  and  prolonged  compression,  is  movable,  has  foi'med 
gradually,  and  has  a  history  of  constipation.  In  the  sigmoid  colon  and 
rectum  digital  exploration  will  demonstrate  the  nature  of  the  mass. 
Vomiting,  tenderness,  and  shock,  so  common  in  acute  obstruction,  are 
absent,  or,  if  present,  only  occur  in  the  latter  stages  and  in  extreme 
cases. 

The  treatment  consists  in  the  repeated  injection  of  warm  water  until 
the  bulk  of  the  tumor  is  softened,  when  laxatives  may  be  given  by  the 
mouth.  The  method  of  injection  is  as  follows :  Place  the  patient  in  the 
knee-elbow  position,  or  upon  the  right  side  with  the  pelvis  elevated.  In 
this  position  the  pressure  is  in  great  part  taken  off  the  rectum,  and  a 
greater  degree  of  tolerance  is  obtained.  If  tenesmiis  results,  a  full  hypo- 
dermic injection  of  morphia  should  be  administered.  The  fountain-irri- 
gator  is  the  best  instrument,  and  from  two  to  four  pints  or  more  may 
be  thrown  slowly  in  at  one  operation.  The  water  should  be  allowed  to 
remain  in  the  colon  as  long  as  possible.  When  the  impaction  is  near 
the  anus,  it  may  be  removed  with  the  finger  or  by  a  spoon. 

Foreign  Bodies. — Indigestible  substances  of  various  kinds,  intro- 
duced by  accident  or  intentionally,  at  times  pass  through  the  stomach 


OBSTRUCTIOX    OF   THE   ALIMENTARY    CAXAL.  531 

into  the  intestitial  canal  and  become  lodged.      In  rarer  instances  tLiev 
are  introduced  througli  the  anus. 

Biliary  calculi  which  have  passed  through  the  common  duct  into 
the  duodenum,  or  causing  ulceration  of  the  gall-bladder  and  duodenal 
wall,  enter  the  canal  in  this  manner,  may  also  cause  intestinal  occlu- 
sion. Again,  obstruction  has  been  caused  in  a  number  of  instances  by 
concretions  (enteroUthes)  composed  of  magnesia,  iron,  or  any  inorganic  ' 
matter  administered  for  a  long  period  of  time.  They  are  met  with  chiefly 
in  the  colon  as  a  solid  mass,  or  are  precipitated  upon  organic  and  indi- 
gestible matter  in  the  canal. 

The  symptoms  vary  with  the  suddenness  or  completeness  of  the 
obstruction,  as  well  as  with  its  location.  Sudden  occlusion  is  accom- 
panied by  pain  of  a  colicky  and  violent  character,  usually  refeiTed  to 
the  seat  of  the  obstruction.  Shock  is  also  present  in  acute  stoppage 
of  the  canal.  Vomiting  is  an  early  and  prominent  symptom  of  occlu- 
sion of  the  small  intestine,  coming  on  at  a  much  later  period,  when 
the  colon  is  inTolvecL  On  the  other  hand,  constipation  is  a  feature 
of  stoppage  in  the  large  intestine,  while  fecal  matter  in  varying  quan- 
tity may  contintie  to  pass  per  anura  for  several  days  after  occlusion 
above  the  ileo-coecal  valve.  In  arriving  at  a  diagnosis,  palpation  and 
perctission  wiU  be  of  value.  The  knowledge  of  the  accident  when  a 
body  has  been  swallowed  will,  of  course,  establish  the  character  of 
the  occlusion.  Insane  or  hysterical  individuals  often  indulge  in  such 
practices.  Biliary  colic  not  infrequently  precedes  occlusion  from  cal- 
culi which  escape  by  the  common  duct,  while  tenderness  in  the  region 
of  the  liver  and  dtiodenum  must  be  present  in  a  varying  degree  in 
cases  of  perforation  of  the  duodenal  wall  by  large  calculi  from  the  gall- 
bladder. 

Tenderness  is  also  present  in  cases  where  delicate  sharp  objects  I'pins. 
needles,  etc.)  have  passed  through  the  walls  of  the  intestine  and  are 
wandering  in  the  cavity  of  the  peritonaeum  or  in  the  pelvis. 

The  treatment  which  should  be  instituted  in  obstruction  by  foreign 
bodies  will  depend  in  great  part  upon  the  symptoms  which  ensue.  If 
the  occlusion  is  complete  and  the  symptoms  are  alarming,  operative  in- 
terference shotild  not  be  delayed.  The  only  doubt  which  may  be  thrown 
upon  the  propriety  of  operating  is  the  presence  of  shock  or  collapse  in 
an  extreme  degree.  If  this  condition  is  present,  morphine  and  whisky 
hypodermically  should  be  administered  in  the  effort  to  bring  about  re- 
action. If  no  urgent  symptoms  follow  the  presence  of  a  foreig-n  Iwdy  in 
the  alimentary  canal,  expectant  measures  may  be  employed  in  the  hope 
that  it  may  pass  out  by  the  rectum.  When  a  foreign  body  has  been 
swallowed  and  has  gone  beyond  the  stomach,  and  its  shape  is  known  to 
be  sitch  that  it  may  cause  perforation  of  the  intestinal  wall,  or  that  the 
possibility  of  its  being  passed  through  is  remote,  it  is  the  wiser  policy 
not  to  lose  valuable  time  by  procrastination,  but  to  operate  at  once. 
When  intioduced  through  the  anus  or  lodged  in  the  rectum  or  lower 
portion  of  the  sigmoid  flexure  of  the  colon,  they  may  be  removed 
through  the  natural  opening. 


532 


A  TEXT-BOOK   ON  SURGERY. 


Intussusception,  or  the  telescoping  of  one  part  of  the  intestinal  canal 
into  another,  may  occur  at  any  portion  of  the  bowel  (Fig.  533).  It  is 
met  with  in  the  following  order  of  frequency  :  at  the  ileo-colic  region, 
the  lower  part  of  the  jejunum  and  ileum,  and  the  colon. 

The  invagination  is  usually  from  above  downward  ;  in  rare  instances 
from  below  upward.     Very  exceptionally  both  conditions  exist  in  the 

same  subject.*    It  oc- 
-T-T,..,^  curs  in  males  more  Ire- 

quently  than  in  fe- 
males, and,  while  it 
may  be  met  with  at 
any  period  of  life,  it 
is  much  more  common 
in  children  than  in 
adults.  A  large  pro- 
portion of  cases  occur 
in  the  first  six  years  of 
life,  and  of  these  the 
first,  second,  and  third 
years  are  most  prolific. 
Intussusception  is 
usually  caused  by  spas- 
modic contraction  of 
a  limited  portion  of 
the  circular  muscular 
fibers  of  the  intestinal 
wall,  whereby  this  por- 
tion, becoming  small- 
er and  firmer,  is  either 
overlapped  and  in- 
cluded by  the  part  im- 
mediately below,  or 
falls  into  it.  Paralysis  of  the  circular  muscle  would  produce  the  same 
condition.  It  may  result  from  the  dragging  of  a  neoplasm  developed  in 
the  wall  of  the  gut,  from  the  lodgment  of  a  foreign  body,  or  fecal  matter. 
Invagination  may  be  acute  or  chronic,  may  cause  com^^lete  obstruc- 
tion at  once,  or  only  partially  occlude  the  intestinal  canal  during  its  en- 
tire existence.  The  character  of  the  symi^toms  will  in  part  depend  ujDon 
the  location  of  the  accident. 

When  the  ileum  and  coecum  are  involved,  the  symptoms  of  obstruc- 
tion are  more  acute.  In  subacute  and  chronic  cases  the  colon  is  usually 
involved. 

The  symptoms  of  intussusception  may  be  those  of  acute  or  gradual 
obstruction,  as  the  invagination  is  acute,  subacute,  or  chronic. 

In  general,  pain  is  present,  and  is  continuous  or  spasmodic,  being 
referred  to  the  region  in  which  the  lesion  exists.     Tenderness  is  not 


Fig.  533. — Tntussusception  of  the  .iejunum.     a,  Intcvnal  cylinder, 
i,  Middle  cylinder,    c,  External  cylinder.     (After  Treves.) 


'Intestinal  Obstruction,"  by  Frederick  Treves.     Lea,  Sons  &  Co.,  Philadelphia,  1884. 


INTUSSUSCEPTION.  533 

present  at  first,  bat  is  developed  as  tlie  inflammatory  changes  in  the 
intestine  and  peritonaeum  appear.  Vomiting  occurs  early  when  the  ob- 
struction is  in  the  small  intestine,  and  later  when  the  large  intestine  is 
involved.  Tenesmus  exists  in  a  certain  proportion  of  cases,  and  is 
especially  apt  to  occur  in  intussusception  in  the  colon.  Fecal  matter 
may  pass  in  complete  obstruction  above  the  colon  until  the  contents  of 
the  large  intestine  are  evacuated,  and  may  persist  throughout  the  attack 
when  the  occlusion  of  the  gut  is  only  partial.  Mucus  and  blood  are  dis- 
charged in  those  cases  in  which  tenesmus  is  exti'eme. 

The  symptoms  of  shock  and  collapse  are  present  early  in  the  history 
of  a  majority  of  all  cases.  The  tumefaction  caused  by  the  invagination 
may  be  felt  through  the  abdominal  wall  or  per  rectum.  The  distention 
of  the  abdomen  is  not  great  when  the  lesion  is  in  the  jejunum  or  ileum. 
It  is  apt  to  be  present  when  the  colon  is  affected. 

The  prognosis  is  always  grave.  Death  occurs  in  70  per  cent  of  all 
cases,  being  about  equal  in  'both  sexes  (Treves).  The  only  methods  of 
recovery,  if  left  to  nature,  are  accidental  reduction,  sloughing  and  elimi- 
nation of  the  invaginated  gut,  or  fecal  fistula.  Accidental  reduction 
can  only  take  place  in  the  milder  varieties  and  in  the  earlier  stages,  be- 
fore adhesions  or  strangulation  have  occurred. 

Distention  of  the  intestine  by  gas,  or  assuming  a  suitable  position, 
might  reduce  the  invagination.  Sloughing  occurs  in  a  certain  proportion 
of  cases,  the  dead  gut  being  passed  by  the  rectum. '  Fecal  fistula  may 
form  in  very  exceptional  instances. 

Treatment. — The  conservative  treatment  consists  in  the  administra- 
tion of  an  anodyne  to  relieve  pain  and  spasm,  and  the  introduction  of 
tepid  water  in  volume  into  the  rectum  and  colon,  with  inversion  of  the 
patient,  or  the  employment  of  gas  or  air  in  a  like  manner.  If  the  lesion 
is  recent,  and  if  it  is  located  in  the  large  intestine,  this  practice  should 
be  tried.  As  it  is  often  impossible,  and  under  all  conditions  extremely 
difficult,  to  overcome  the  resistance  of  the  ileo-coecal  valve,  it  is  an  im- 
justifiable  waste  of  time  to  attempt  a  reduction  by  these  measures  in  in- 
tussusception above  the  ileo-colic  junction. 

The  objections  to  this  method  of  treatment  may  be  formulated  thus : 
1.  The  administration  of  opium  masks  the  symptoms  by  dulling  sensi- 
bility, and  may  induce  a  dangerous  if  not  fatal  procrastination  of  more 
radical  and  certain  measures.  2.  Distention  from  below  by  water,  gas, 
or  air — within  the  limit  of  safety  from  rupture — fails  to  reduce  an  invagi- 
nation in  which  strangulation  or  adhesions  have  occurred.  In  all  proba- 
bility only  the  mildest  forms  are  reducible  by  this  method,  even  when 
no  adhesions  exist.  3.  It  fails  in  such  a  vast  majority  of  cases  that  it 
induces  a  procrastination  in  surgical  interference,  and  of  itself  induces 
a  certain  amount  of  shock,  which  in  a  measure  detracts  from  the  prog- 
nosis after  abdominal  section. 

The  only  means  of  decreasing  the  heavy  mortality  following  intussus- 
ception is  in  abdominal  section.  It  is  important  that  the  operation  be 
not  deferred  too  long ;  in  fact,  not  longer  than  the  recognition  of  the 
lesion.     Within  the  first  twenty-four  hours  the  prognosis  will  be  much 


534  A  TEXT-BOOK   ON  SURGERY. 

more  favorable,  and  the  clanger  of  a  fatal  termination  will  be  increased 
with  each  day  thereafter. 

In  favor  of  abdominal  section  it  may  be  said  :  1.  That  a  death-rate  of 
70  per  cent  in  treatment  without  operation  justifies  surgical  interference. 
2.  It  is  now  well  known  that,  in  a  patient  not  exhausted  by  asthenia  or 
prolonged  suffering,  exploration  of  the  abdominal  cavity  under  careful 
antiseptic  precautions  is  attended  with  little  danger,  and,  in  the  earlier 
hours  of  intestinal  obstruction,  it  does  not  add  much  to  the  gravity  of 
the  prognosis.  3.  If  recovery  by  sloughing  occurs,  stricture  of  the  in- 
testine is  always  to  be  considered  as  a  probable  sequel.  If  the  invagi- 
nation is  reduced  early,  or  if  exsection  is  practiced,  stenosis  will  rarely 
occur.  4.  In  the  rare  cases  of  recovery  by  fecal  fistula,  operative  inter- 
ference is  ultimately  demanded. 

If  the  point  of  obstruction  can  be  definitely  located,  and  is  not  near 
the  median  line,  the  abdominal  incision  should  be  made  immediately 
over  the  occluded  intestine.  Under  other  conditions,  the  median  line 
near  the  umbilicus  should  be  selected.  The  invagination  should  be  over- 
come, if  possible,  by  gentle  traction  or  massage,  leaving  the  intestine 
within  the  abdominal  cavity.  If  necessary,  the  mass  may  be  drawn  out 
and  kept  warm  with  towels.  The  questions  of  excision  and  anastomosis, 
or  artificial  anus,  must  be  determined  by  the  conditions  present. 

Volvulus,  or  twisting  of  a  loop  of  intestine,  occurs  usually  in  the  sig- 
moid flexure  of  the  colon,  although  the  remaining  portions  of  the  colon, 
or  coecum  and  small  intestine,  may  be  occluded  by  this  accident.  The 
loop  may  become  twisted  upon  itself  at  its  mesenteric  attachment,  or 
one  loop  may  be  twisted  over  a  second.  The  last  variety  is  more  apt  to 
occur  in  the  ileum  and  lower  jejunum.  The  principal  cause  of  volvulus 
is  an  abnormally  long  mesentery,  allowing  unusual  freedom  of  motion  to 
the  loop  of  intestine  which  is  attached  to  it.  This  defect  may  be  congeni- 
tal or  acquired.  Constipation  and  the  habitual  distention  of  the  sigmoid 
flexure  by  fecal  matter  is  probably  the  most  frequent  cause  of  elongation 
of  the  meso-colon  and  increased  length  of  this  part  of  the  large  intestine. 
It  occurs  more  frequently  in  men  than  in  women,  and  is  met  with  in 
adults  more  than  in  children.  When  the  conditions  are  favorable,  a  suit- 
able position  or  an  accident  in  movement  is  sufficient  to  rotate  the  loop 
on  its  axis,  causing  occlusion  by  the  weight  of  the  loop  and  mesentery 
brought  to  bear  upon  a  limited  surface.  The  symptoms  of  volvulus  are 
those  of  acute  intestinal  obstruction.  Pain  similar  to  that  of  colic  is  pres- 
ent from  the  start.  Constipation  is  the  rale,  and  indicates  the  sigmoid 
colon  as  the  seat  of  the  lesion.  Tenesmus  is  present  in  a  certain  number 
of  cases,  and  is  additional  evidence  that  the  colon  is  involved.  Disten- 
tion of  the  abdomen  to  an  extreme  degree  occurs  in  a  large  proportion 
of  cases,  developing  more  rapidly  in  volvuhis  of  the  colon.  Vomiting  is 
rarely  present  until  late  in  the  history  of  the  case,  and,  when  it  appears 
early,  it  suggests  obstruction  in  the  small  intestine.  A  condition  of  shock 
more  or  less  profound  supervenes  if  relief  is  not  obtained.  Diminution 
in  the  quantity  of  urine  is  present  in  a  certain  proportion  of  cases. 

The  i3rognosis  is  fatal  probably  without  exception  in  every  case  of 


CONSTRICTION  BY  BANDS.— DIVERTICULA.  535 

complete  volvulus.  Strangulation  of  the  loop  and  enormous  distention 
of  the  part  involved  occur. 

Treatment. — If  the  symptoms  point  to  the  sigmoid  flexure  or  colon 
as  the  seat  of  the  twist,  the  introduction  of  warm  water  into  the  rectum 
is  indicated.  The  patient  should  be  placed  in  the  knee-elbow  position. 
The  introduction  should  be  made  gradually,  and  may  prove  successful 
in  recent  cases  where  adhesions  have  not  occurred,  or  where  the  disten- 
tion of  the  gut  is  not  too  great.  If  this  measure  is  not  successful  within 
a  few  hours,  abdominal  section  should  be  performed,  the  hand  intro- 
duced, and  the  loop  untwisted. 

Constriction  hy  Bands. — Bands  of  cicatricial  tissue  resulting  from 
peritonitis  cause  intestinal  obstruction  in  a  certain  proportion  of  cases. 
This  accident  occurs  chiefly  m  adults,  about  equally  in  both  sexes,  being 
due  to  pelvic  inflammations  in  women  and  to  typhlitis  and  traumatic 
peritonitis  in  men  (Treves).  The  bands  vary  in  length,  breadth,  and 
points  of  attachment.  The  lower  jejunum  and  ileum  are  involved  in 
almost  all  cases.  The  symptoms  are  in  general  those  of  acute  obstruc- 
tion of  the  small  intestine.  Pain  is  violent  in  the  beginning,  and  in  the 
majority  of  cases  is  referred  to  the  part  involved.  Vomiting  is  an  early 
and  pei'sistent  symptom,  and,  as  is  common  in  obstruction  above  the 
lleo-coecal  valve,  is  apt  to  be  stercoraceous.  Shock  is  usually  more 
prominent  in  this  form  of  occlusion  than  in  those  heretofore  given.  The 
urine  is  diminished  in  quantity.  The  abdomen  is  not  tympanitic  as  a 
rule,  although  the  constricted  loop  may  be  greatly  distended,  and  may 
be  recognized  as  a  distinct  tumor  by  palpation  or  percussion,  or  by  vagi- 
nal or  rectal  exploration. 

The  diagnosis  must  be  made  from  the  history  of  a  former  peritonitis 
and  the  presence  of  the  symptoms  above  given.  The  prognosis  is  fatal, 
and  the  indication  for  treatment  is  early  operative  interference. 

In  addition  to  inflammatory  bands,  intestinal  occlusion  is  occasionally 
caused  by  the  pedicle  of  an  ovarian  or  uterine  tumor,  or  the  Fallopian 
tube  may  act  in  the  same  manner. 

Adhesions  between  contiguous  loops  of  intestine,  resulting  from  peri- 
tonitis, may  occur  in  such  a  manner  as  to  lead  to  occlusion.  The  symp- 
toms do  not  differ  materially  from  those  just  given,  and  the  treatment 
is  the  same. 

Strangulation  tJirough  Slits  in  the  Omentum  and  Mesentery. — Occa- 
sionally a  loop  of  intestine  slips  through  an  opening  in  the  omentum  or 
mesentery,  becomes  imprisoned  and  strangulated.  The  rent  may  be  con- 
genital or  result  from  an  injury,  penetrating  or  non-penetrating.  The 
small  intestine  (ileum)  is  most  frequently  involved,  and  the  aperture  oc- 
curs as  a  rule  in  the  mesentery  of  the  last  part  of  this  organ.  Strangula- 
tion of  the  colon  in  this  manner  is  exceedingly  uncommon.  AVith  the 
exception  of  the  presence  of  a  tumor,  the  symptoms  are  the  same  as 
those  in  hernia  of  the  small  intestine  with  strangulation.  Early  opera- 
tive intei'ference  ofl:ers  the  only  hope  of  relief. 

Constriction  by  Diverticula.  —  Pouches  or  cavities  communicating 
with  or  attached  to  the  intestines  may  be  true  or  false— i.  e.,  congenital 


536  A  TEXT-BOOK  ON  SURGERY. 

or  acquired.  Meckel's  diverticulum,  which  is  attached  to  the  last  two  or 
three  feet  of  the  ileum,  may  remain  patulous  and  open  at  the  umbilicus, 
or  more  frequently  it  ends  in  a  blind  extremity  which  may  be  continued 
as  a  cord  to  the  umbilicus.  When  it  exists  it  represents  the  vitelline 
duct  of  the  embryo,  in  which  the  normal  process  of  closure  and  oblitera- 
tion has  not  taken  place.  The  vermiform  appendix  may  also  be  classed 
with  the  true  diverticula.  False  diverticula  occur  in  both  the  small  and 
large  intestine,  being  slightly  more  common  in  the  colon.  Their  mode 
of  origin  is  not  as  yet  satisfactorily  explained.  They  are  fonnd  to  pro- 
ject between  the  two  layers  of  peritonseum  along  the  mesenteric  border 
of  the  small  intestine,  and  into  the  appendices  epiploicse  of  the  colon 
(Treves).  They  are  hernise  of  the  mucous  membrane  projecting  through 
an  aperture  in  the  muscular  layer. 

Constriction  and  strangulation  of  a  loop  of  intestine  by  Meckel's  di- 
verticulum are  much  more  apt  to  occur  than  by  the  false  pouches.  The 
vermiform  appendix  in  rare  instances  may  become  twisted  upon  its  axis 
and  strangulated,  or  it  may  cause  the  constriction  of  a  neighboring  loop 
of  the  ileum. 

There  are  no  symptoms  peculiar  to  obstruction  from  true  or  false 
diverticula,  and  the  nature  of  the  lesion  can  only  be  discovered  by 
abdominal  section,  which  is  indicated  in  this  form  of  intestinal  occlusion. 

Neoplasms. — Various  new-formations,  both  benign  and  malignant  in 
character,  may  occur  in  the  intestinal  canal  and  lead  to  obstruction  by 
projecting  into  the  lumen  of  the  gut,  or  by  pressure  from  without  or  by 
development  within  the  wall  proper,  producing  narrowing  or  stricture. 
Fibroma,  flbro-myoma,  and  lipoma  are  of  rare  occurrence.  Angioma 
is  also  exceptional  in  this  location.  Adenoma  is  a  more  common  form, 
developing  from  the  glandular  apparatus,  and  more  particularly  from 
the  follicles  of  Lieberkiihn  in  the  large  intestine. 

Sarcoma  and  carcinoma  are  also  met  with,  both  as  primary  and 
secondary  growths.  The  symptoms  of  obstruction  are,  as  a  rule,  gradual 
in  development,  and  the  presence  of  a  tumor  may  be  recognized  by  pal- 
pation with  the  abdominal  muscles  in  complete  relaxation.  Cancer  is 
the  most  common  of  these  new  formations,  and  is  apt  to  be  located  in 
the  colon  or  rectum.  According  to  Haussmann  and  Treves,  the  variety 
of  cancer  met  with  in  the  large  majority  of  instances  is  a  cylindrical 
epitheMoma,  encephaloid  and  scirrhus  being  very  exceptional.  The 
growth  may  cause  constriction  by  extending  completely  around  the 
lumen  of  the  tube,  or,  by  developing  on  one  side,  cause  stenosis  by  its 
bulk  and  by  the  contractions  which  result.  The  diagnosis  of  cancer 
may  be  made  in  those  cases  in  which  the  disease  is  situated  in  the  rec- 
tum or  lower  portion  of  the  sigmoid  flexure  by  digital  examination  or 
by  the  aid  of  the  speculum.  Situated  higher  up,  the  presence  of  a 
tumor,  the  age  of  the  patient  (over  forty  as  a  rule),  and  the  peculiar 
cachexia,  will  aid  in  arriving  at  a  correct  diagnosis. 

Stricture. — The  partial  or  complete  occlusion  of  an  intestine,  by  cica- 
tricial contractions  following  inflammation  or  ulceration  of  its  mucous 
and  submucous  or  muscular  layers,  constitutes  a  true  intestinal  stricture. 


STRICTURE.  537 

Constriction  by  peritoneal  bands,  or  the  infiltration  accompanying  can- 
cer, is  not  considered  as  stricture  proper. 

Any  disease  which  produces  loss  of  substance  in  the  inner  layers  of 
the  wall  of  the  gut  may  produce  stricture.  The  ulcers  of  typhoid  fever, 
tuberculosis,  dysentery,  syphilis,  and  chronic  intestinal  catarrh,  or  those 
resulting  from  injury  by  ingested  matter,  by  traumatism,  or  the  necrosis 
following  strangulated  hernia,  are  the  chief  lesions  which  precede  true 
stricture  of  the  intestine.  Cicatrization  in  an  ulcer  which  has  its  long- 
est axis  at  a  right  angle  to  that  of  the  intestine  is  more  apt  to  lead  to 
obstruction  than  one  which  has  its  long  axis  in  an  opposite  direction. 
Stricture  occurs  in  adults,  of  forty  years  or  more,  oftener  than  in  the 
young,  being  rarely  met  with  in  children  under  ten  years  of  age.  No 
portion  of  the  alimentary  canal,  from  the  pylorus  to  the  anus,  is  exempt, 
yet  stricture  of  the  duodeniim  and  upper  jejunum  is  comparatively  rare  ; 
the  ileum,  near  the  csecum,  is  more  frequently  attacked,  while  the  large 
intestine,  and  especially  the  sigmoid  flexure  and  rectum,  is  the  most 
common  seat  of  this  grave  and  painful  affection. 

The  symptoms  of  stricture  are  those  of  progressive  narrowing  of  the 
intestine.  The  intensity  of  the  symptoms  will  be  proportionate  to  the 
rapidity  with  which  stenosis  results  and  to  the  portion  of  the  canal  in- 
volved. Pain  is  not  marked  until  the  narrowing  has  arrived  at  a  i^oint 
where  ingested  matter  passes  through  with  difficulty.  It  is  spasmodic  in 
character,  and  occurs  at  varying  intervals.  Distention  of  the  intestine 
above  the  seat  of  stricture,  with  consequent  hypertrophy  of  the  wall, 
follows  sooner  or  later  in  all  cases.  The  continued  irritation  of  the  bowel 
from  the  pressure  of  fecal  matter  induces  ulceration  of  the  mucous  and 
submucous  tissues  at  and  above  the  seat  of  stenosis,  and  perforation 
may  occur. 

Vomiting  is  an  earlier  symptom  in  stricture  of  the  ileum  and  jeju- 
num than  when  the  colon  is  involved.  There  may  be  diarrhoea  or  con- 
stipation, or  these  conditions  may  alternate,  and  are  therefoi-e  of  no 
diagnostic  value.  Tenesmus  is  rare,  and  the  abdomen  is  not  distended 
except  in  case  of  peritonitis.  As  far  as  the  previous  history  may  be  of 
value  in  locating  the  seat  of  the  lesion,  it  is  known  that  dysenteric  ulcers 
are  usucilly  found  in  the  rectum,  sigmoid  flexure,  and  caecum,  and  in 
the  order  of  frequency  in  which  these  organs  are  given  :  typhoid  ulcers 
(which  rarely  cause  stricture)  in  the  lower  ileum  and  Cfecum  ;  those  of 
chronic  catarrh  in  the  colon  ;  syphilis  (gumma)  in  the  rectum  and 
ileum  ;  and  tubercular  ukers  in  the  lower  ileum  (Treves). 

The  diagnosis  of  stricture  must  be  based  upon  a  study  of  the  symp- 
toms above  given,  except  the  cases  in  which  the  lesion  is  in  the  rectum 
or  lower  part  of  the  sigmoid  flexure,  where  digital  or  instrumental  ex- 
ploration may  be  made. 

Treatment.— StrictnTe  of  the  rectum  and  lower  part  of  the  sigmoid 
flexure  of  the  colon  should  be  treated  by  dilatation  or  division.  Above 
this  point  the  only  hope  of  relief  is  by  exsection  of  the  part  involved,  or 
by  lateral  intestinal  anastomosis.  On  account  of  the  comparative  freedom 
of  this  last  operation  it  should  be  preferred.     Enterostomy  and  colos- 


538  A  TEXT-BOOK  ON  SURGERY. 

tomy  are  palliative  surgical  measures,  to  be  instituted  wlien  other  means 
are  not  indicated. 

Abdominal  Section  fok  Intestinal  Occlusion. 

In  all  lesions  of  the  small  intestines  and  of  the  transverse  colon  in 
which  it  becomes  necessary  to  invade  the  abdominal  cavity,  the  incision 
should  be  made  in  the  linea  alba,  between  the  umbilicus  and  the  sym- 
physis pubis,  extending  it  to  a  higher  point  if  necessary.  When  the 
seat  of  the  obstruction  can  not  be  determined  without  exploration,  the 
same  incision  should  be  practiced.  The  caecum,  ascending  and  descend- 
ing colon,  can  be  more  directly  approached  from  an  opening  in  the  lat- 
eral aspects  of  the  abdomen  immediately  over  these  viscera.  The  sig- 
moid flexure  and  upper  portion  of  the  rectum  may  be  well  exposed  by 
the  median  incision  when  the  small  intestines  and  mesenteiy  are  lifted  to 
one  side.  In  general,  it  may  be  said  that  the  smaller  the  incision  the 
better,  yet  the  opening  should  always  be  sufficient  to  admit  of  thorough 
exploration,  and,  if  necessary,  large  enough  for  inspection.  The  patient 
should  rest  upon  the  back,  with  the  head  and  shoulders  slightly  elevated, 
in  order  to  relax  the  abdominal  muscles.  Strict  attention  should  be  paid 
to  the  antiseptic  details  already  given.  An  efl'ort  should  be  made  to  strike 
the  median  line  so  exactly  that  the  incision  will  pass  between  the  two 
recti  muscles.  All  bleeding  should  be  arrested  before  the  parietal  peri- 
tonseum  is  incised.  This  should  be  punctured,  and  a  very  dull-pointed, 
grooved  director  inserted,  and  the  peritonaeum  divided  on  tliis  instru- 
ment. The  opening  should  be  at  least  four  inches  in  length.  As  soon 
as  this  is  accomplished,  the  disinfected  hand  should  be  introduced  and 
the  seat  of  obstruction  sought.  The  escape  of  intestines  or  omentum 
through  the  wound  should  be  prevented  by  holding  large  flat  sponges 
or  aseptic  napkins  prepared  for  this  purpose  over  these  viscera  and  press- 
ing them  back  into  the  peritoneal  cavity.  All  sponges,  towels,  etc., 
brought  in  contact  with  the  viscera  should  be  disinfected  in  Thiersch's 
solution,  since  the  ordinary  sublimate  solutions  are  too  irritating.  If, 
upon  exposing  the  small  intestines,  some  of  the  coils  are  found  to  be 
greatly  distended  while  others  are  collapsed,  it  is  pretty  safe  to  conclude 
that  the  obstruction  is  near  at  hand,  and  the  collapsed  loops  should  be 
carefully  passed  between  the  fingers  up  to  the  obstruction.  It  is  scarcely 
possible,  in  the  condition  in  which  the  viscera  will  be  found,  to  deter- 
mine exactly  which  is  the  upward  or  downward  direction  of  the  coils, 
and  it  may  be  necessary  to  begin  at  the  caecum  and  work  upward. 

If  the  coils  wdiich  present  are  so  enormously  distended  that  they  in- 
terfere with  the  exploration,  the  gas  should  be  evacuated  by  multiple 
puncture  with  the  finest  hypodermic  needle.  The  gas  escapes  through 
the  needle,  the  hole  made  by  which  is  so  delicate  that  it  is  closed  by  con- 
traction of  the  muscular  fibers  of  the  gut.  Should  a  larger  puncture  be 
necessary,  it  should  be  closed  by  Lembert's  silk  suture. 

When,  as  not  infrequently  happens,  by  reason  of  procrastination  in 
asking  for  surgical  relief,  the  condition  of  the  patient  is  so  critical  that  a 


ABDOMINAL   SECTION   FOR   INTESTINAL   OCCLUSION.       539 

prolonged  operation  is  not  indicated,  it  is  a  practice  I  have  found  suc- 
cessful in  several  instances  to  seize  the  first  presenting  loop  of  distended 
intestine,  stitch  it  to  the  abdominal  wound,  and  establish  immediately 
an  artificial  anus.  The  alarming  symptoms  of  obstruction  thus  allayed, 
the  occlusion  can  be  dealt  with  at  a  subsequent  operation. 

If  the  csecum  is  found  to  be  distended,  the  lesion  is  evidently  in  the 
colon,  and  this  organ  should  be  followed  to  the  obstruction.  If  biliary 
calculi,  a  foreign  body,  or  enteroliths  are  found,  the  part  involved  in  the 
obstruction  should,  if  possible,  be  brought  out  at  the  wound,  protected 
by  warm  Thiersch  towels,  the  escape  of  matter  into  the  cavity  of  the  peri- 
tonaeum prevented  by  flat  sponges  or  napkins,  and  the  body  removed  by 
an  incision  in  the  long  axis  of  the  gut,  and,  when  possible,  opposite  the 
mesenteric  attachment.  The  length  of  the  opening  should  be  sufficient 
to  allow  of  the  removal  of  the  body  without  bruising  or  tearing.  If  the 
part  can  net  be  brought  out,  it  should  be  laid  upon  a  flat  sponge  and  the 
peritonaeum  in  this  way  protected  from  the  escape  of  fecal  contents.  This 
accident  may  be  in  great  part  prevented  by  compression  of  the  gut  above 
the  obstruction.  The  wound  in  the  intestinal  wall  is  next  closed  by  Lem- 
bert's  suture. 

When  intussusception  exists,  the  invaginated  portion  should  be 
brought  into  full  view,  and  careful  traction  employed  in  the  effort  at 
reduction.  If  this  can  not  be  accomplished,  or  if  strangulation  and 
necrosis  exist,  exsection  of  the  necrosed  portion  should  be  made  at  once, 
if  the  condition  of  the  fjatient  is  such  as  to  justify  a  prolonged  opera- 
tion. If  not,  the  dead  loop  or  portion  should  be  brought  out  at  the  in- 
cision in  the  abdomen,  cut  away,  and  a  fecal  fistula  established.  The 
restoration  of  the  intestinal  canal  may  be  accomplished  at  a  subsequent 
operation.  If  the  operation  has  not  been  too  long  postponed,  it  will  be 
advisable  to  proceed  with  the  exsection  at  once. 

Exsection — or,  as  it  is  sometimes  called,  resection — of  the  intestine 
is  a  very  proper  operation,  and  one  which,  when  performed  early  enough, 
with  the  careful  attention  to  details  it  requires,  will  succeed  in  the  ma- 
jority of  cases. 

This  operation,  heretofore  so  rarely  perfonued  with  success,  is  one  of 
such  importance  that,  in  describing  the  technique,  the  following  case  is 
given  in  detail : 

Leah  E, ,  Russian,  fifty-six  years  of  age,  housewife,  was  admitted 

to  Mount  Sinai  Hospital  on  October  9,  1886,  with  the  following  history : 
For  ten  years  she  had  had  a  swelling  in  the  left  groin,  which  would  dis- 
appear when  she  was  lying  down  and  return  when  she  was  standing  erect. 
She  had  not  worn  a  truss.  Two  weeks  before  admission  she  discovered 
that  the  tumor  no  longer  disappeared  upon  going  to  bed,  but  became 
painful,  tender',  and  more  swollen.  She  had  not  vomited  up  to  the  time 
of  arriving  at  the  hospital,  but  there  had  been  no  evacuation  of  the  bow- 
els for  six  days  prior  to  her  admission. 

On  admission,  a  swelling  as  large  as  an  ordinary  fist  was  found  occu- 
pying the  inner  aspect  of  the  left  groin  and  thigh.  The  skin  over  the 
tumor  was  red  in  color,  tender  and  doughy  to  the  touch,  and  fluctuation 


540  A  TEXT-BOOK   ON   SURGERY. 

was  evident.  The  tissues  around  were  slightly  emphysematous.  The 
patient's  ajjpetite  was  gone  ;  she  was  emaciated,  having  lain  in  her  pres- 
ent condition  ten  days  in  a  tenement-house,  without  proper  care.  The 
temperature  was  normal. 

A  diagnosis  of  strangulated  femoral  hernia  was  made,  ether  adminis- 
tered, and  the  tumor  incised.  Several  ounces  of  foul  pus  mixed  with 
intestinal  matter  were  discharged.  No  trace  of  a  hernial  sac  or  of  intes- 
tine could  be  discovered,  such  was  the  gangrenous  condition  of  the  mass. 
Upon  introducing  the  little  finger  into  the  femoral  canal,  a  slight  opening 
into  the  intestine  could  be  felt.  Into  this  a  closed  dressing-forceps  was 
introduced,  and  the  opening  dilated  by  separating  the  jaws  of  this  instru- 
ment. This  was  intended  to  secure  the  freer  exit  of  ingested  matter 
from  the  upper  portion  of  the  occluded  gut. 

A  loose  dressing  of  iodoform  gauze  was  laid  over  the  wound.  The 
patient  improved  in  condition  after  this  operation,  under  mild  stimu- 
lation and  liquid  diet  (milk,  beef-tea,  beef-juice,  whisky,  sherry,  etc.). 
Only  a  small  quantity  of  ingested  matter  escaped  when  the  gauze  dress- 
ing was  changed  on  every  second  or  third  day. 

On  October  22d,  thirteen  days  after  the  first  operation,  with  ether 
narcosis,  laparotomy  was  performed.  The  patient  was  placed  upon  the 
back,  with  the  pelvis  elevated  upon  a  firm  cushion.  With  Volkmann's 
spoon  the  granulation  tissue  was  first  scraped  from  the  walls  of  the 
abscess,  the  hole  into  the  intestine  plugged  with  a  pellet  of  iodoform 
gauze,  the  cavity  of  the  abscess  irrigated  with  1-to-lOOO  sublimate,  and 
then  tightly  packed  with  iodoform  gauze. 

The  integument  about  the  femoral  canal  was  washed  thoroughly  with 
soap  and  warm  water,  cleanly  shaved,  washed  with  ether,  and  finally 
with  1-to-lOOO  sublimate  solution.  Towels  wrung  out  of  hot  sublimate 
solution  (l-to-3000)  were  laid  over  that  portion  of  the  body  near  the 
groin,  leaving  only  a  spot  exposed  measuring  six  by  fou^r  inches. 

An  incision  four  inches  in  length  was  made  parallel  with  the  outer 
border  of  the  rectus  muscle,  the  lower  end  being  over  the  femoral  ring. 
All  bleeding  was  arrested,  so  that  before  the  peritonaeum  was  opened  the 
wound  was  absolutely  dry.  Catgut  ligatures  were  employed.  Great  care 
was  observed  to  keep  to  the  inner  side  of,  and  away  from,  the  epigastric 
vessels  which  were  exposed  in  the  dissection.  The  parietal  layer  of  the 
peritonaeum  was  picked  ujp  with  a  fine  forceps,  opened,  and  further 
divided  upon  the  finger  as  a  director. 

Upon  looking  into  the  abdominal  cavity,  one  or  two  loops  of  normal 
small  intestine  were  seen,  and,  upon  displacing  these  upward,  a  third 
looj)  was  seen  to  be  imprisoned  in  the  femoral  opening.  That  part  of 
this  loop  above  the  constriction  was  slightly  distended,  while  the  part 
on  the  side  nearest  the  rectum  was  contracted  until  it  was  about  two 
thirds  of  the  diameter  of  the  upper  segment.  The  obstruction  of  the 
intestinal  canal  at  the  ring  was  complete.  A  soft,  flat  sponge  taken 
from  a  warm  Thiersch  solution  (boric  acid,  gr.  iv. ;  salicylic  acid,  gr.  j ; 
water,  3])  was  placed  beneath  the  imprisoned  loop  in  such  a  manner 
that  it  held  the  loose  loops  of  small  intestine  back,  and  was  ready  to 


ABDOMINAL  SECTION  FOR  INTESTINAL  OCCLUSION.       541 

receive  any  foreign  matter  whicli  might  escape  from  the  gut  when  it  was 
divided. 

Two  long-jawed  scissors-forceps  (used  as  clamps)  were  then  placed  so 
as  to  close  the  loop  of  gut  which  was  caught  in  the  ring.  One  of  these 
rested  against  the  inner  surface  of  the  ring,  and  the  other  only  sufficiently 
removed  from  this  to  permit  of  a  division  of  the  intestine  between  the 
foi'ceps. 

.  As  soon  as  this  was  effected,  the  loose  end,  with  one  pair  of  forceps 
attached,  was  brought  out  through  the  abdominal  wound  and  placed  in  a 
warm  Thiersch  towel.  As  the  forceps  which  constricted  the  ring  of  gut 
attached  to  the  femoral  canal  was  removed,  a  tuft  of  sponge  was  tightlj^ 
packed  into  this  ring  to  prevent  any  infection  from  the  abscess  with 
which  it  communicated. 

Of  the  loop  which  had  been  liberated,  about  ten  inches  (five  above 
and  below  the  point  of  occlusion)  were  drawn  out  of  the  abdomen,  flat 
Thiersch  sponges  carefully  placed  so  as  to  close  the  wound  and  prevent 
any  escape  of  matter  into  the  jDeritoneal  cavity,  and  the  exposed  gut  pro- 
tected by  covering  Avith  warm  towels.  A  piece  of  cotton  tape  one  fourth 
of  an  inch  wide  was  then  tied  four  inches  above  and  below  the  limits  of 
the  gangrenous  opening,  so  as  to  completely  occlude  the  lumen  of  the 
gut  {d,  d,  Fig.  533  a).     These  tapes  had  been  well  soaked  in  a  l-to-3000 


Fia.  533  A. — Loop  of  small  intestines,  a,  h,  Lines  of  section  tbrouarh  the  gut,  removins  the  gangrenous 
portion,  b.  c,  Same  throush  the  mesentery,  a,  a,  Gangrenous  "portion  of  ileum,  a,  d.  Occlusion  of 
the  afferent  and  efferent  tubes  by  tape  Ugatures. 


sublimate  solution.  When  the  forceps-clamp  was  removed,  the-opening 
into  the  intestine  was  seen  to  occupy  two  thirds  of  the  circumference  of 
the  canal.  The  gut  was  then  cut  across  at  a  right  angle  to  its  axis  by  a 
single  stroke  with  the  straight  scissors  (a,  b,  Fig.  533  a).     These  lines  of 


542  A   TEXT-BOOK  ON   SURGERY. 

section  were  well  out  in  sound  tissue.  The  piece  of  intestine  removed 
measured  two  inches  and  a  half.  A  triangular  piece  of  the  mesentery 
was  also  removed  (b,  c,  b,  Fig.  533  a).     • 

The  bleeding  from  the  mesentery  was  profuse,  reqtiiring  a  dozen  cat- 
gut ligatures.  From  the  ends  of  the  intestine  only  a  slight  oozing  oc- 
curred. The  cavity  of  the  gut  from  the  tapes  to  the  openings  was  carer 
fully  emptied  of  all  matter  and  washed  out  with  Thiersch's  solution. 
Nothing  escaped  from  the  lower  end. 

The  edges  of  the  divided  mesentery  were  first  united  by  eight  inter- 
rupted catgut  sutures  about  one  fourth  of  an  inch  distant  from  each 
other.  When  the  intestine  was  reached,  the  mesenteric  attachment  of 
each  end  was  carefully  brought  into  apposition  and  the  work  of  stitch- 
ing the  ends  of  the  cylinders  to  each  other  begun. 

In  doing  this,  three  forms  of  suture  were  employed :  1.  A  suture 
through  the  mucous  membrane  alone — Czerny's  suture.  2.  That  through 
the  peritoneal  coat  alone — LemberVs  suture.  3.  One  which  pierces  the 
peritoneal  coat  and,  passing  along  with  the  muscular  layer,  comes  out 
on  the  free  border  of  the  divided  gut — the  intermediate  suture.* 

In  Fig.  533  b,  which  represents  a  longitudinal  section  through  the 
ends  to  be  approximated,  is  shown  at  h  the  Czerny  sutixre  as  it  is  passed 

through  the  mucous  layer  of 
r^  the  gut  from  the  inner  sur- 

Peritoneai  layer.         face  of  the  caual ;  while  at  a 
Muscular  layer.  the  method  of  introducing  the 

Mucous  membrane.      Lembert  suture  through  the 
peritoneal  layer  is  shown. 

Fia.  533 B.— Sohematic.     o,  Lembert's  Whpn  fi   o-nt  i«  put    «inrn«« 

suture.    A,  Czeruy's  suture.  ^^  ^^U  a  gUt  IS  CUt   acrOSS, 

the  longitudinal  muscular  lay- 
er retracts,  carrying  the  peritoneal  layer  with  it,  and  leaving  the  thick 
mucous  membrane  projecting  about  one  eighth  of  an  inch.  The  object 
of  the  Czerny  suture  is  to  bring  the  mucous  membrane  and  the  con- 
nective tissue,  upon  which  it  rests,  together,  and  thus  strengthen  the 
line  of  union  after  adhesion  occurs.  If  this  is  not  done,  the  slight  adhe- 
sions between  the  peritoneal  surfaces  obtained  by  the  Lembert  suture 
might  give  way  under  the  strain  of  distention 

of  the  intestine  by  gas  or  ingested  matter.       -^ 'y^  —  ^ 

The   objection  to   passing  a  suture   entirely      ^Si ""    ~  ' 


through   the  wall  of  the  gut,   and  thus  ap- 
proximating all   the   coats  at   once,  is   the  dan-       Fio.   533  c— Schematic.     Showin? 
,1      .     ,,  J!        i-  1        J   n  T    1  the  inversion  of  the  peritoneal 

ger  that  the  perforation  may  be  followed  by  layer  by  tying  Lembeit's  suture, 
escape  of  gas  or  other  contents  to  either  side  byl-remy'!  s'Sturel'  "'"'^''^^ 
of  the  line  of   adhesion  between   the  ends. 

The  inversion  of  the  mucous  membrane  by  Czerny's  suture,  and  of  the 
peritoneal  layer  by  Lembert's  suture  after  the  threads  are  tied,  is  shown 
in  Fig.  533  c. 

*  Dr.  Sntton,  of  Pittsburg,  employed  this  suture  in  a  case  which  ended  in  a  good  recov- 
ery. I  saw  the  line  of  union  in  this  patient  about  two  years  after  the  operation,  througli  the 
courtesy  of  Professor  J.  B.  Hunter,  who  was  performing  a  second  laparotomy. 


; —  Muscular  layer. 


ABDOMEN^AL  SECTION  FOR  INTESTINAL  OCCLUSION.       543 

Tlie  mechanism  of  the  intermediate  suture  is  well  shown  in  Pig. 
533  D.     This  suture  adds  strength  to  the  union  by  taking  in  the  mus- 
cular layer  and  connective  tissue  of  the  mucous  membrane,  together 
with  the  peritoneal  cov- 
ering.     Applied    after 
the  Czemy  suture,  there 
can  be  no  danger  of  es- 
cape   of    the  intestinal 

contents      through      the  ^  Mucous  membrane. 

Fig.  533  d. — Schematic.     Shoinng  the  route 
wound.  of  the  intermeJiate  sutures.  / 

In  suturing  the  in- 
testine, the  very  finest  black  silk,  and  delicate  straight  or  half-curved 
needles,  should  be  used.  The  thread  should  be  made  aseptic  in  sub- 
limate solution  (l-to-3000),  and  it  and  the  needle  taken  from  a  l-to-20 
carbolic-acid  solution  as  they  are  used.  In  commencing  the  sutures, 
fii-st  insert  one  Czemy  suture  just  at  the  mesenteric  or  attached  bor- 
der of  the  intestine,  and  tie  this,  the  knot,  of  course,  coming  within 
the  lumen  of  the  gut.  The  needle  should  pass  from  within  through 
the  mucous  layer  at  a  distance  of  about  three  sixteenths  of  an  inch 
from  the  free  border  (Fig.  533  b),  out  along  the  free  border  of  the  same 
end,  and,  being  carried  across  to  the  opposite  end,  should  be  made  to 
enter  below  the  muscular  and  mucous  layer,  and  to  emerge  through  the 
mucous  layer  three  sixteenths  of  an  inch  from  its  cut  edge.  A  Lem- 
bert  suture  should  be  next  inserted  just  at  the  edge  of  the  mesenteric 
attachment,  as  follows :  *  The  needle  is  made  to  enter  the  peritoneal  coat 
one  eighth  of  an  inch  from  the  edge,  and,  passing  between  the  serous  and 
mucous  coats,  is  again  brought  through  the  peritoneal  layer  about  one 
twenty-fifth  of  an  inch  from  the  edge  (Fig.  533  b,  «).  At  a  point  exactly 
opposite,  the  same  stitch  is  passed  through  the  peritoneal  layer  of  that 
side  for  the  same  distance,  and  this  thread  is  tied.  In  knotting  all  of 
these  sutures,  it  is  a  wise  precautiou  to  use  the  double  or  friction  knot 
for  the  first  tying,  for  by  so  doing  there  is  no  danger  of  the  suture  slip- 
ping and  the  parts  separating  as  the  second  turn  is  being  made.  A  sec- 
ond Lembert  suture  should  now  be  inserted  on  the  other  side  of  the  mes- 
enteric attachment,  and  an  intermediate  suture  passed  between  these, 
through  the  substance  of  the  mesentery  and  down  into  the  strip  of  intes- 
tine which  here  is  uncovered  by  peritonaeum.  Extra  care  must  he  taken 
to  see  that  this  part  of  eaxh  end  of  the  cylinder  is  in  perfect  coaptation. 
The  sutures  are  now  inserted  for  the  remainder  of  the  apposing  surfaces. 
The  Lembert  and  intermediate  sutures  alternate  through  the  entire  cir- 

*  Wien  the  peritoneal  surfaces  of  tlie  intestine  are  held  in  apposition  by  this  suture,  adhe- 
sion occurs  in  a  remarkably  short  time.  In  January,  1S87, 1  was  called  in  consultation  in  a  ca^e 
of  suspected  volvulus.  Upon  opening  the  abdomen,  it  was  found  impossible  to  untwist  the 
loop  without  puncture  and  evacuation  of  the  contents  of  the  greatly  distended  gut.  The 
opening,  one  fourth  of  an  inch  long,  was  closed  by  four  Lembert  sutures  at  11.30  a.  m.  Three 
and  one  half  hours  later  the  patient  died.  On  autopsy,  not  only  had  weU-marked  adhesion 
taken  place,  but  the  silk  threads  were  with  difficulty  recognized,  being  hidden  beneath  the  in- 
flammatory exudation. 


544 


A  TEXT-BOOK  ON  SURGERY. 


cumference,  and  should  be  one  eightli  of  an  incli  apart.  The  mucous 
or  Czerny  sutures  should  be  from  one  fourth  to  three  eighths  of  an  inch 
apart.  The  relative  proportion  of  these  sutures  is  shown  in  Fig.  533  e. 
It  is  evident  that  while  the  Czerny  suture  is  tied,  leaving  the  knot  within 
the  cavity  of  the  intestine  for  the  first  part  of  the 
operation,  the  last  few  threads  must  be  tied  leav- 
ing the  knot  imbedded  between  the  mucous  and 
muscular  layers  of  the  wall.  In  applying  the  sut- 
ures, the  plan  followed  was — first  a  Czerny,  then 
a  Lembert  about  over  this,  next  an  intermediate, 
another  Lembert,  and  after  this  a  second  Czerny 
suture,  and  so  on.  In  other  words,  it  was  neces- 
sary to  insert  the  mucous  suture  before  the  super- 
ficial sutures  had  quite  reached  that  point.  All  of 
the  thi'eads  should  be  cut  off  close  to  the  knot. 

In  this  operation  I  had  to  leave  the  space  be- 
tween the  sutures  on  the  upper  end  of  the  gut  a 
little  wider  than  on  the  lower,  for  the  diameter  of 
the  efferent  tube  was  considerably  smaller  than  that  of  the  afferent  por- 
tion. The  intervening  space  was  a  flush  one  eighth  of  an  inch  on  one 
side,  and  a  scant  one  eighth  of  an  inch  on  the  other.  When  the  sutures 
were  all  in.  the  constricting  tapes  were  removed.  The  gut  immediately 
filled  with  gas.  To  the  surprise  of  all  present,  the  intestine  below  the 
line  of  suture  instantly  expanded  to  a  size  equal  to  that  of  the  portion 


Fig.  533  e.— Schematic. 
Section  of  intestine,  showing 
tlie  proportion  of  each  form 
ofsuture,  and  their  distance 
apart.  I,  Lembert.  »,  In- 
temiediate  sutures  alternat- 
ing, c,  Czerny's  sutures. 
(Natural  size.) 


Fig.  533  f.— Showin, 


the  mesentery  and  around  the  intestine. 


above  the  line  of  union.  That  the  wound  was  tightly  closed,  was 
demonstrated  by  forcing  the  contents  of  the  intestine  from  opposite 
directions  toward  the  sutures.     No  gas  escaped. 


ABDOMINAL   SECTION   FOR   INTESTINAL   OCCLUSION.       545 

Tlie  appearance  after  the  tapes  were  removed  is  shown  in  Fig.  533  f. 
At  intervals  of  about  five  minutes  during  the  operation,  a  small  quantity 
of  warm  Thiersch  solution  was  poured  over  the  exposed  intestine.  The 
warm  Thiersch  towels  upon  which  it  rested  were  changed  every  ten  or 
fifteen  minutes.  No  fluid  was  allowed  to  get  into  the  abdominal  cavity. 
Finally,  the  intestine  was  carefully  washed  with  this  solution,  and  re- 
turned into  the  cavity  of  the  peritonaeum. 

It  was  now  necessary  to  deal  with  the  ring  of  intestine  which  occu- 
pied the  femoral  opening,  and  which  led  from  the  abscess  into  the 
abdominal  cavity.  Two  strong  silk  threads  were  passed  entirely  through 
the  opposing  walls  of  this  rim  of  intestine,  and  tied  so  as  to  bring  the 
edges  well  together.  I  then  passed  a  silver  probe  from  the  hernial 
abscess  cavity  up  through  the  femoral  canal,  and  through  the  ring  of 
adhering  intestine  between  the  two  silk  threads,  until  the  end  of  the 
probe  projected  a  half -inch  into  the  cavity  of  the  abdomen.  The  ends  of 
both  threads  were  tied  to  the  i^robe,  and  this  withdrawn,  bringing  the 
sutures  oiit  through  the  saphenous  opening.  By  making  strong  and 
continuous  traction  on  these,  the  mucous  membrane  was  everted,  the 
peritoneal  surfaces  brought  in  contact,  and  the  femoral  opening  closed. 
This  procedure  effected  a  radical  cure  of  the  hernia. 

The  wound  in  the  parietal  layer  of  peritonaeum  was  closed  by  catgut 
sutures.  The  abdominal  incision  was  closed  with  silk  sutures,  which 
included  all  the  tissues  down  to  (but  not  touching)  the  peritonaeum. 
For  the  prevention  of  ventral  hernia  after  laparotomy,  it  is  very  im- 
portant to  include  the  fascia  and  aponeuroses  of  the  muscles  in  the 
sutures.  A  Neuber's  bone-drain  was  inserted.  The  abscess  and  sinus 
were  packed  with  iodoformized  gauze.  The  patient  rallied  well,  and 
was  kept  quiet  with  suppositories  of  opium.  She  was  kept  on  the  back, 
and  was  not  permitted  to  move  body,  legs,  or  arms  for  ten  days.  The 
d.iet  was  milk,  beef-tea,  and  whisky  in  small  quantities. 

October  23,  6  a.  m.,  fourteen  hours  after  operation,  temperature  99°  F. 
Patient  vomited  at  4.30  a.  m. 

October  s'^.— Pulse,  120 ;  temperature,  99°  to  100°. 

October  25. — Pulse,  100;  temj^erature,  99.6°.  Patient  comfortable. 
Slept  well. 

October  26. — The  pulse  and  temperature  were  the  same. 

October  ^7.— Pulse,  80  to  100  ;  temperature,  98.4°  to  99.6°-. 

October  25.— Pulse,  100  ;  temperature,  99°  to  100°. 

October  ."J^.— Pulse,  100  to  106  ;  temperature,  99.2°.  Bowels  moved  ; 
stool  normal  consistence. 

October  30.— V wise  94  to  100  ;  temperature,  99.2°  to  100.2°  F.  Bowels 
moved  again  ;  stool  nonnal.     Opium  discontinued. 

The  subsequent  history  contains  nothing  of  interest.  The  patient 
steadily  gained  her  strength.  On  November  20th  she  sat  up  in  bed,  and 
on  December  3d  was  walking  about  the  ward.  She  is  now  fully  restored 
and  attending  to  her  duties.  There  is  no  sign  of  obstruction  or  interfer- 
ence with  the  functions  of  the  alimentary  canal,  and  the  hernia  is  at  this 
date  radically  cured.  The  great  emaciation  of  the  patient  at  the  time  of 
35 


546  A  TEXT-BOOK  ON   SURGERY. 

operation,  and  the  fact  that  within  half  an  inch  of  the  opening  into  the 
abdomen  there  was  a  large  abscess  cavity,  may  be  mentioned  as  the  two 
conditions  which  rendered  the  prognosis  grave. 

Exsection  of  the  colon  is  somewhat  more  difficult  than  the  operation 
upon  the  small  intestine,  on  account  of  its  irregularity  in  size  and  the 
deeper  location  of  all  of  this  organ  except  the  transverse  portion.  It 
should  be  brought  into  or  out  of  the  incision  if  possible,  or,  if  this  can 
not  be  done,  the  opening  in  the  linea  alba  may  be  enlarged  in  the  direc- 
tion best  suited  to  the  case.  If,  after  exploration  through  an  incision  in 
the  linea  alba,  the  obstruction  is  found  to  be  in  the  caecum,  ascending  or 
descending  colon,  and  the  part  involved  is  so  firmly  fixed  that  it  can 
neither  be  brought  into  view  through  the  wound  in  the  median  line  nor 
by  an  additional  transverse  incision  of  two  or  three  inches,  it  will  be 
advisable  to  close  this  opening  and  expose  the  part  by  an  incision  imme- 
diately over  it. 

When,  for  any  of  the  reasons  about  to  be  submitted,  lateral  anasto- 
mosis is  determined  upon,  the  method  of  Senn,  as  modified  by  Abbe, 
will  be  found  superior  to  the  more  tedious  operation  by  suture  practiced 

by  Woeller  and  others.      In  its 
'^  performance  the  catgut  rings  of 

^S^  Abbe  (Fig.  533  g)  are  preferable 

—  ~^  to  Senn' s  absorbable  bone-plates. 

(         .      "      ^~  '-  _  The  laborious   investigations  of 

'^  ,         ,_-___-_;~^  "  Professor  Senn,  of  Wisconsin,  in 

\  ^  -  the  department  of  intestinal  sur- 

""^  ■;  gery  are,  it  is  believed,  already 

II         "~  yielding  gratifying  results.     The 

rings  are  thus  prepared  : 

Fio.  533  G. — Sliowins  the  construction  of  Abbe's  ,,    .  -,         .    i       i  .        . 

catgut  rings.  A  moderately  heavy  catgut 

is  chosen  ;  taken  from  alcohol  or 
juniper-oil,  it  is  wound  loosely  on  a  test-tube  and  soaked  in  hot  water. 
It  soon  kinks  w]),  and  were  it  not  on  a  tube  could  hardly  be  unraveled. 
After  a  while  it  is  straightened  out,  allowed  to  untwist,  wound  again 
loosely,  and  soaked  in  hot  water  once  more,  until  it  ceases  to  twist.  It 
is  then  ready  to  make  up  into  rings,  which  will  lie  perfectly  flat.  Eight 
or  ten  turns  over  two  pins  stuck  in  a  cork  two  inches  apart,  will  make  a 
bundle  somewhat  smaller  than  a  lead-pencil.  These  may  be  tied  at  four 
places  with  fine  silk,  to  secure  the  strands  parallel  while  being  wound 
round  like  a  cable,  with  a  continuous  piece  of  the  same  catgut.  The 
end  of  the  piece  is  secured  by  threading  it  into  a  Hagedorn  needle,  and 
transfixing  the  whole  bundle  obliquely  with  it  at  the  place  of  finishing. 
Thus  there  are  no  knots,  and  it  is  difficult  to  find  the  point  of  beginning. 

"  The  ring  is  now  a  long  oval  with  an  inside  diameter  of  two  inches, 
and  in  thickness  smaller  than  a  pencil.  Six  strong  but  small  braided 
silk  threads  are  now  fixed  to  each  ring,  equidistant,  on  the  face  looking 
toward  the  other  ring  which  is  to  be  laid  against  it. 

"  No  knots  are  used.  A  needle  pierces  the  ring  between  the  strands, 
carrying  the  thread,  which  is  drawn  through,  all  but  eight  inches,  and 


ABDOMIXAL   SECTION    FOR   INTESTINAL    OCCLUSION.       54.7 


r 


\Wl 


:\\ 


Fig.  5o3  h. — iietii'xi  uf  pre:?ervmg  and  liartening  the  rio^. 

■wound  once  and  a  half  round,  sinking  between  the  encircling  catgut, 
piercing  the  ring  again,  and  cut  off.  The  rings,  which  hare  now  been 
water-soaked,  are  ready  for  use  if  needed  for  emergency ;  but,  if  possi- 


FiG.  533 1. — Showing  the  method  of  passins;  the  siJk  sutures  in  inserting  the  rings. 
In  iiG.  533  J  the  ring  is  in  position. 


548 


A  TEXT-BOOK   ON  SURGERY. 


ble,  they  should  be  kept  awhile  in  alcohol,  under  pressure  between  two 
glass  slides  (Fig.  533  h),  the  threads  being  curled  up  within  the  oval, 
and  the  sides  being  pressed  as  the  glasses  are  tightly  tied  together. 
The  ring  thus  becomes  a  long  oval  with  parallel  sides,  and  soon  be- 
comes harder  and  flattened  on  its  faces.  Moreover,  it  shrinks  a  trifle 
in  alcohol,  to  swell  again  in  the  intestine  and  give  additional  security. 

"In  using  the  rings, 
I  find  it  saves  time  for 
each  thread  to  have  its 
own  needle.  The  intes- 
tine is  pierced  from  within 
outward  less  than  a  quar- 
ter of  an  inch  from  its  cut 
edge  (Fig.  533 1).  The  ring 
should  be  laid  on  a  damiD 
folded  towel  with  threads 
in  order  and  needles  stuck 
in  the  towel,  which  is  held 
by  the  assistant  close  to 
the  bowel,  while  the  op- 
erator quickly  pulls  the 
threads  through  and  pass- 
es the  ring  into  the  inte- 
rior of  the  bowel.  When 
the  threads  are  tied  and 
cut  off,  the  apposition  is 
perfect,  but  by  a  quickly 
made  running  suture  out- 
side all,  a  half -inch  of  peri- 
toneal surface  is  at  once 
secured  beyond  the  pos- 
sibility of  leakage  (Fig. 
533  j).  More  than  this  is 
superfluous,  for  the  edges 
held  between  the  rings  act 
as  valves. 

"In  invaginating  the 
end  of  the  cut  intestine 
after  exsection,  one  will 
delay  a  long  while  if  he  tries  to  turn  in  first  one  and  then  the  other  edge, 
and  will  also  find  the  mesentery  try  to  turn  in  after  it  on  the  attached 
side.  My  rule  is  to  trim  back  the  mesentery  at  least  a  half-inch  from 
the  end.  Then,  seizing  both  lips  with  toothed  forceps,  plunge  them 
directly  into  the  lumen.  The  entire  edge  usually  follows,  and  one  holds 
them  by  the  left  index-finger  and  thumb  while  a  quick  running  overhand 
suture  of  the  slit  thus  formed  is  made."  * 


Fig.  533  j. — Lateral  ana'-tomosis  complete.    Intestine  fenestrated 
to  show  opening  Irom  cue  bectiun  ot  ihe  gut  into  the  other. 


*  "Intestinal   Anastomosis,"  Eobert  Abbe,  M.  D. 
Philadelphia  Medical  Society,"  1889. 


Reprinted  from  "  Transactions  of  the 


ABDOMINAL  SECTION  FOR  INTESTINAL   OCCLUSION.       549 

The  application  of  this  method  is  especially  indicated  in  establish- 
ing the  integrity  of  the  intestinal  canal  in  malignant  disease  or  other 
obstruction  where  excision  of  the  occluded  portion  is  not  practicable, 
as  in  g  astro- enter  ostomy  from  cancer  of  the  pyloris ;  or  in  any  condi- 
tion where  a  prolonged  operation  is  contra-indicated.  If  in  the  fur- 
ther use  of  the  rings  they  can  be  employed  in  direct  or  terminal  anas- 
tomosis, a  great  advance  will  be  made,  for  in  lateral  anastomosis  the 
pockets  necessarily  existing  are  objectionable.  The  question  of  time  is, 
however,  in  a  class  of  cases  of  such  vital  importance  that  this-  method 
may  be  preferred  to  the  more  tedious  process  of  direct  suture  (terminal 
anastomosis).  In  anastomosis  between  the  small  and  the  large  intestine 
it  should  be  employed. 

Fecal  fistula  is  established  by  bringing  the  loop  or  portion  of  intes- 
tine which  is  involved  in  the  obstruction  into  the  wound  and  stitching  it 
to  the  edges  of  the  incision  as  directed  in  gastrostomy.  Strangulated 
and  necrotic  portions  should  be  cut  away. 

If  the  obstruction  is  due  to  volvulus,  it  will  be  indicated  by  unusual 
distention  of  the  twisted  loop,  which,  in  case  the  sigmoid  flexure  is 
involved,  is  enormous.  An  effort  should  be  made  to  untwist  the  gut 
vrithout  puncture ;  but  if  this  can  not  be  accomplished,  the  hypodermic 
needle  should  be  employed  as  above  directed.  In  case  of  gangrene  or 
adhesions  amounting  to  stricture  at  the  point  of  crossing  of  the  two  por- 
tions of  the  gut,  the  operation  of  exsection  or  for  fecal  fistula  should  be 
done. 

When  the  constriction  is  caused  by  peritoneal  bands,  these  should  be 
divided  and  the  intestine  liberated.  If  a  loop  of  intestine  has  been 
caught  beneath  the  pedicle  of  a  tumor  (of  the  ovary,  uterus.  Fallopian 
tubes,  etc.),  the  occlusion  may  be  relieved  with  or  without  removal  of 
the  offending  body. 

In  adhesions  of  the  contiguous  peritoneal  surfaces  of  a  loop  of  intes- 
tine, or  the  matting  together  of  several  loops  in  such  a  manner  that 
obstruction  occurs,  exsection  or  the  formation  of  a  fecal  fistula  is  indi- 
cated. If  the  adhesions  are  limited,  they  may  be  dissected  apart ;  but 
this  procedure  is  not  unattended  with  danger  from  sloughing  or  a  recur- 
rence of  the  lesion. 

Strangulation  or  constriction  of  a  loop  of  gut  in  a  slit  of  the  mesen- 
tery or  omentum  should  be  treated  by  enlarging  the  slit,  reduction  of 
the  loop,  and  closure  of  the  opening  by  catgut  sutures.  If  necrosis  has 
resulted,  exsection  or  the  formation  of  a  fistula  may  be  done.  In  limited 
necrosis  the  dead  portion  may  be  cut  away  and  the  hole  closed  by  Lem- 
bert's  suture,  provided  that  the  lumen  of  the  gut  is  not  too  greatly 
occluded  by  this  operation,  and  always  provided  that  the  margins 
through  which  the  sutures  pass  are  sound. 

Intestinal  obstruction  due  to  diverticula  should  be  treated  by  division 
of  the  constricting  tissues.  A  false  diverticulum  can  scarcely  be  removed 
with  safety,  but,  if  necessary,  Meckel's  diverticulum  or  the  vermiform 
appendix  may  be  excised.  In  closing  the  stump  of  the  appendix,  the 
peritoneal  coat  should  be  turned  in  by  Lembert's  suture. 


550  A   TEXT-BOOK   ON   SURGERY. 

The  removal  of  neoplasms  may  require  tlie  exsection  of  a  part  of  the 
intestinal  canal.  In  general,  the  rules  above  laid  down  are  applicable 
here.  Cylindrical  epitheliomata,  with  no  infiltration  of  the  neighboring 
lymjahatics  or  mesentery,  are  included  among  neoplasms  which  may 
with  propriety  be  excised.  When,  however,  the  extent  of  the  infiltra- 
tion is  such  that  a  complete  removal  is  improbable,  the  palliative  opera- 
tion of  forming  a  fistula  is  advisable. 

Stricture  of  the  intestine  above  the  rectum  may  be  excised  in  favor- 
able cases,  or  life  may  be  prolonged  by  establishing  an  artificial  opening 
in  the  gut  above  the  seat  of  occlusion.  Exsection  will  afford  a  more 
satisfactory  result  in  the  majority  of  instances  when  undertaken  before 
the  patient  is  exhausted  by  inanition  and  prolonged  suffering. 

When  the  obstruction  is  located  in  the  lower  portion  of  the  ileum  or 
in  the  first  part  of  the  colon,  ileo-colostomy  may  be  performed  when 
exsection,  in  order  to  be  successful,  must  be  an  extensive  procedure.  In 
this  operation  the  end  of  the  ileum  is  stitched  to  the  margins  of  a  suitable 
opening  in  the  colon  below  the  obstruction.  It  is  analogous  to  gastro- 
enterostomy. 

Hernia. — Literally  defined,  a  hernia  is  a  tumor  formed  by  the  escape 
of  the  whole  or  a  portion  of  any  viscus  from  its  normal  cavity.  The  term 
is  now  by  common  consent  almost  wholly  restricted  to  protrusions  of 
intestine  or  omentum  (or  both)  from  the  cavity  of  the  abdomen  or  pelvis. 
The  protrusion  may  occur  through  an  opening  which  is  congenital  or 
acquired.  Complete  inguinal  hernia  following  the  descent  of  a  testicle, 
or  ventral  hernia,  due  to  failiire  of  perfect  union  in  the  aponeuroses  of 
the  abdominal  muscles,  are  instances  of  the  former ;  while  a  protrusion 
of  the  intestine  after  a  wound  in  the  abdominal  wall  is  an  example  of 
the  latter.  The  hernia  may  take  place  into  an  adjoining  cavity,  as  the 
thorax  (diaphragmatic),  or  protrude  beneath  the  skin  (femoral,  umbilical, 
ventral,  etc.). 

Herniee  are  classified  according  to  their  place  of  escape :  inguinal, 
femoral,  umbilical,  ventral,  diaphragmatic,  gluteal,  obturator,  lumbar, 
and  vaginal.  The  term  ventral  is  applied  to  all  hernige  occurring  at 
points  on  the  abdominal  wall  other  than  those  indicated  in  the  classifi- 
cation just  given.  Of  hernige  in  general  the  inguinal  variety  forms  about 
80  per  cent  of  all  cases  ;  femoral,  10  ;  umbilical,  5  ;  the  remaining  vari- 
eties, 5.     Of  every  five  patients  affected  with  hernia  four  are  males. 

Inguinal  hernia  in  males  occurs  more  often  in  the  first  ten  years  of 
life  than  in  any  subsequent  decade,  the  period  from  the  twentieth  to 
the  fortieth  year  being  next  in  order  of  frequency.  According  to  King- 
don,  femoral  hernia  in  males  of  all  ages  is  met  with  in  4  of  every  100 
cases  ;  in  the  first  decade,  in  1  of  every  300  ;  the  second,  2  per  cent ;  the 
third  and  fourth  together,  4^  per  cent ;  the  fifth  and  sixth,  6  per  cent ; 
and  after  this,  8  per  cent. 

In  females,  inguinal  and  femoiul  hernige  are  met  with  in  about  equal 
proportions.  The  latter  variety  is  rarely  met  with  before  puberty,  but 
occurs  chiefly  during  the  child-bearing  period  (Bryant). 

The  contents  of  a  hernia  are  inclosed  in  a  sac  almost  always  formed 


INGUINAL  HERNIA. 


551 


by  the  peritonseum  lining  the  abdominal  cavity.  The  sac  may  be  car- 
ried immediately  in  front  of  the  escaping  intestine  or  omentum  (femoral, 
umbilical,  etc.),  or  these  viscera  may  descend  into  a  sac  already  formed 
by  the  escape  of  some  other  organ  (inguinal,  scrotal).  In  the  rare  cases 
of  hernia  of  those  portions  of  the  large  intestine  not  covered  by  perito- 
nseum there  is  no  true  sac.  If  the  intestine  alone  enters  into  the  forma- 
tion of  a  hernia,  it  is  called  enter ocele ;  if  omentum  alone,  epiplocele ;  if 
both  are  inclosed  in  the  sac,  entero-e-pvplocele.  The  coverings  of  a  hernia 
outside  of  the  sac  will  vary  with  its  location,  and  will  be  given  in  the 
consideration  of  the  different  varieties.  A  hernia  is  said  to  be  reduciMe^ 
when  the  contents  of  the  sac  can  by  any  means  be  returned  into  the  cav- 
ity of  the  abdomen  ;  irreducible^  when  adhesions  exist  to  such  an  extent 
that  this  can  not  be  eflEected  ;  strangulated,  when  the  circulation  in  the 
tumor  is  arrested  by  constriction  at  any  portion  (usually  at  the  neck). 


Fig.  534. — The  relations  of  the  points  of  escape  of  oblique  and  direct  inguinal  and  obturator  hernise  to  the 
important  vessels  of  the  pelvis.  1,  Internal  abdominal  ling.  2,  Point  at  which  a  direct  inguinal 
hernia  commences.     3,  Obturator  canal,  artery,  and  nerve.     (Modified  from  Maclise.) 


Special  HernicB,  Inguinal. — An  inguinal  hernia  may  be  direct  or 
indirect,  complete  or  incomplete,  congenital  or  acquired. 

The  indirect  or  "oblique"  variety  is  much  more  frequently  met  with. 
In  the  male  the  contents  pass  into  the  internal  abdominal  ring  and  follow 


552 


A  TEXT-BOOK   ON   SURGERY. 


the  spermatic  cord  along  the  inguinal  canal,  at  times  descending  into  the 
tunica  vaginalis  testis.  In  the  female  the  descent  is  in  the  canal  of 
Nuck,  following  the  round  ligament  into  the  inguinal  canal,  and  at  times 
as  far  as  the  labium.  The  epigastric  vessels  are  internal  to  the  necTc, 
and  behind  the  body  of  an  oblique  inguinal  hernia  (Figs.  534  and  646). 


Fia    535. — Showing,  at-1  and  2,  openinirs  at  which  oblique  and  direct  hernise  escape,  and  their  relations 
to  the  deep  epigastric  artery.     (Modified  from  MacUse.) 


A  direct  hernia  does  not  enter  the  internal  abdominal  ring,  but  pushes 
the  fascia,  which  is  to  the  inner  side  of  the  epigastric  vessels  and  imme- 
diately behind  the  external  ring,  directly  in  front  of  the  tumor  and  out 
at  the  external  ring.  The  epigastric  vessels  are  external  to  the  necJc, 
and  may  be  displaced  slightly  in  front  and  to  the  outer  side  of  a  direct 
inguinal  hernia  (Figs.  535  and  545). 

An  inguinal  hernia  is  said  to  be  complete  when  the  contents  protrude 
beyond  the  external  ring ;  incomplete,  when  the  tumor  is  within  this 
limit. 

A  complete  inguinal  hernia  in  the  male  may  descend  into  the  cavity 
of  the  tunica  vaginalis  testis,  the  contents  resting  in  contact  with  the 


INGUINAL  HERNIA. 


553 


Fig.  536. — Congenital  oblique  inguinal  hernia.  Sac 
formed  by  the  tardea  vaginalis  et  funiculi.  1, 
Cavity  of  the  tuniea.     (After  Maclise. ) 


Fig.  hXi. — Infantile  hernia  (acquired),  the  intes- 
tine carrying  with  it  a  process  of  peritona-um 
by  the  side  of  the  occluded  spermatic  tube. 
(Alter  Maclise.) 


Fig.  538. — Complete  inguinal  hernia  as  it  occurs  an  the 
adult.  Not  communicating  with  the  cavity  of  the 
tunica  vaginalis  testis.     (After  Maclise.) 


testicle  {congenital)  (Fig.  536) ; 
or  it  may  be  arrested  in  the 
tubular  sheath  which  surrounds 
the  spermatic  cord  {infantile), 
the  contents  not  in  contact  with, 
but  pressing  upon,  the  testicle 
(Fig.  537). 

Cause. — Inguinal  hernia  may 
be  congenital  or  acquired.  A 
congenital  hernia  exists  at 
birth,  and  usually  descends 
into  the  tunica  vaginalis  testis. 
It  results  from  the  patulous 
condition  of  the  process  of 
peritongeum,  which  is  carried 
downward  in  the  descent  of 
the  testicle  and  spermatic  cord. 
Acquired  hernia  is  one  which 
comes  on  after  birth.  It  is 
caused  by  the  pressure  of  the 
intestine  or  omentum,  from 
gravity  and  muscular  efPort 
combined. 

Femoral  Tiernia  is  always 


554 


A  TEXT-BOOK   ON   SURGERY. 


acquired.  The  tumor  enters  the  crural  canal  beneath  Poupart's  liga^ 
ment,  just  to  the  inner  side  of  the  iliac  and  femoral  vein  (Fig.  539).  If 
it  remains  in  the  crural  sheath,  it  is  an  incomplete^  but  if  it  protrudes 
at  the  saphenous  opening,  it  is  a  complete  femoral  hernia  (Fig.  540). 


Fig.  539. — Showing  the  femoral  rin;;  and  its  relations  to  the  iliac  vein  and  the  obturator  artery  when 
derived  fi-om  the  deep  epigastric.  1,  Femoral  ring.  2,  Obturator  foramen.  3,  Deep  epigastric  artery. 
4,  Abnormal  origin  of  the  obturator  running  internal  to  the  neck  of  a  femoral  hernia.  5,  The  same, 
descending  external  to  the  nccli  of  a  femoral  hernia.  6,  Normal  obturator  artery.  7,  Circumflex 
branch  of  external  iliac.     (Modified  from  Maclise.) 


Umbilical  hernia  is  congenital  or  acquired.  It  exists  not  infre- 
quently at  birth  in  both  sexes,  on  account  of  the  patulous  conditionof 
the  omphalo-mesenteric  duct.  In  this  variety  the  only  covering  of  the 
tumor  is  the  sheath  of  the  umbilical  cord.  In  the  acquired  form  the 
intestine  escapes  either  directly  through  the  navel,  or  more  frequently  to 
one  side  of  this  contraction.  The  sac  of  an  acquired  umbilical  hernia 
is  composed  of  the  parietal  layer,  of  the  peritonjeum,  and  the  outer  cov- 
ering of  integument. 

Ventral  hernia  may  also  be  congenital  or  acquired.  The  protrusion 
may  occur  at  birth,  as  a  result  of  failure  of  development  in  the  muscles 
of  the  abdomen.  It  is  usually  met  with  along  the  linea  alba  above  the 
umbilicus.  The  acquired  form  may  occur  at  any  point,  and  results  from 
accidental  or  surgical  wounds  of  the  muscles  and  fascia.  It  is  quite 
frequently  met  with  in  the  wounds  of  incision  in  the  operation  of  lapa^ 
rotomy. 


HERNIA. 


555 


Diaphragmatic  Tiernia,  is  usually  due  to  a  wound  or  rupture  of  the 
diaphragm.  It  may  result  from  a  congenital  defect  in  this  muscle.  It 
generally  occurs  on  the  left  side,  on  account  of  the  protection  afforded 
by  the  liver  on  the  right  side. 

Gluteal  hernia  is  extremely  rare.  The  escape  of  the  viscus  is  through 
the  sciatic  notch,  and  it  may  occur  above  or  below  the  pyriformis  muscle. 


^h 


Fig.  540. — Showing  the  relations  of  a  complete  femoral  hernia  to  the  important  organs  of  the  groin. 
1,  Saphenous  "vein  passing  beneath  the  falcifoi-m  process.  2,  Femoral  vein  and  artery.  3,  Crural 
nerve.     4,  Plexus  of  femoral  lymphatic  glands.     (Modified  from  Maclise.) 

Obturator  hernia  takes  place  in  the  thyroid  foramen,  and  usually 
in  the  upper  portion,  in  the  canal  which  gives  exit  to  the  obturator  ves- 
sels and  nerves  (Fig.  534).     It  is  more  common  in  women  than  in  men. 

Lumbar  hernia,  occurs  in  the  region  situated  between  the  twelfth 
rib  and  the  crest  of  the  ilium. 

Hernia  into  the  vagina  occurs  after  partial  or  complete  prolapse  of 
the  uterus,  or  after  loss  of  substance,  allowing  escape  of  the  intestine. 

Symptoms— Inguinal  Hernia.— Wh^ei^.  gradually  acquired,  the  pres- 
ence of  a  small  swelKng  or  tumor  near  the  center  of  Poupart's  ligament, 
or  a  little  to  the  inner  side  of  this  point,  is  usually  the  first  symptom 
of  inguinal  hernia.  In  a  certain  proportion  of  cases  the  appearance  of 
the  swelling  has  been  preceded  by  a  feeling  of  weakness  or  uneasiness 
referred  to  this  region,  which  only  disappeared  when  the  recumbent 


556: 


A  TEXT-BOOK  ON  SURGERY. 


posture  was  assumed,  or  when  strong  upward  pressure  was  made  by  the 
hand. 

If  suddenly  acquired,  the  presence  of  the  tumor  is  noticed  soon  after 
a  violent  strain  of  the  abdominal  muscles.  Pain  is  almost  always  pres- 
ent, and  the  patient  is  generally  aware  of  the  moment  the  rupture  oc- 
curred. 

The  diagnosis  of  inguinal  hernia  involves,  (1)  the  differentiation  be- 
tween the  direct  and  indirect  form,  and  (2)  between  inguinal  and  femoral 
hernise  and  the  various  swellings  which  may  occur  in  this  region ;  vari- 
cocele, hydrocele,  bubo,  incarcerated  testicle,  new  formations,  abscess, 
and  aneurism. 

A  direct  inguinal  hernia  is  exceptional.  The  tumor  foi'med  by  it  is 
apt  to  be  spherical  (Fig.  541),  is  situated  nearer  the  median  line,  and 


/ 


Fio.  5tl  — Duect  inguinal  hernia     (After  Biv ant.)        Fia.  542. — Oblique  inguinal  hernia.     (After  Bryant.) 

the  neck  will  be  found  to  enter  the  abdominal  cavity  immediately  be- 
hind the  external  ring. 

The  tumor  formed  by  an  oblique  inguinal  hernia  (Fig.  542)  is  oval  or 
elliptical  in  the  incomplete,  and  oval  or  pyriform  in  the  complete  variety. 
The  history  of  the  swelling,  if  gradually  de- 
veloped, will  indicate  that  the  tumor  com-  ^  _^^      ^^ 
menced  at  the  middle  of  Poupart's  ligament 
and  traveled  toward  the  pubes.     In  cases  of 
long  standing,  and  when  the  tumor  is  of  large 
size,  the  diagnosis  between  the  direct  and  in- 
direct form  is  scarcely  possible,  from  the  fact 
that  the  inner  edge  of  the  internal  ring  has 
been  dragged  down  until  it  occupies  a  posi- 
tion just  behind  the  external  opening. 

A  femoral  hernia  (Fig.  543)  is  situated  be- 
low Poupart's  ligament,  and  near  its  attach- 
ment to  the  spine  of  the  pubes,  to  the  inner  side  of  the  femoral  vessels. 
In  lean  subjects  the  neck  of  the  tumor  can  be  readily  traced  to  the  canal 
at  this  point.     In  corpulent  persons  the  diagnosis  is  more  difficult. 

The  swelling  of  varicocele  commences  in  the  lower  posterior  portion 
of  the  cord,  and  increases  gradually  upward.     To  the  touch  the  dis- 


Fie.  54.3. — Femoral  hernia. 
(After  Bryant.) 


HERNIA.  557 

tended  veins  feel  like  worms.  The  tumor  has  none  of  the  elasticity  of 
hernia. 

In  the  recumbent  posture  a  varicocele  and  a  non-incarcerated  inguinal 
hernia  will  both  disappear.  If  after  the  disappearance  firm  j)ressure  is 
made  with  the  fingers,  and  the  patient  is  directed  to  resume  the  upright 
posture,  the  varicocele  will  return,  while  the  hernia  can  not  descend. 
Coughing  does  not  affect  varicocele.  The  accumulation  of  fluid  in 
hydrocele  of  the  tunica  vaginalis  is  first  noticed  in  the  most  inferior 
portion  of  the  scrotum  ;  the  swelling  is  spherical  at  first,  and  becomes 
pyriform  after  the  cord  is  involved.  Hydrocele  is  translucent,  and  fluct- 
uation may  be  detected.  Encysted  hydrocele  of  the  cord  near  the 
external  ring  or  within  the  inguinal  canal  may  make  differentiation 
more  difficult.  The  impulse  from  coughing  is  not  marked  in  hydrocele, 
the  sense  of  weakness  is  absent,  the  cyst  is  small  and  usually  remains 
so.  If,  after  full  consideration,  doubt  still  exists,  aspiration  with  the 
finest  hypodermic  needle  will  clear  up  the  diagnosis. 

Bubo. — In  chronic  adenitis  the  glandular  character  of  the  swelling 
can  be  made  out  distinctly. 

In  acute  adenitis,  although  the  peri-lymphatic  infiltration  is  so  exten- 
sive that  the  glands  can  not  be  recognized,  the  redness  of  the  skin,  the 
great  tenderness  on  pressure,  and  the  superficial  character  of  the  pain, 
with  the  coexistence  of  a  urethritis  or  sore  upon  the  penis  or  scrotum, 
will  serve  to  establish  the  character  of  the  lesion. 

Incarcerated  testicle  may  be  suspected  if  there  is  absence  of  the 
organ  on  that  side.  If  the  testicle  is  not  extensively  atrophied,  pressure 
ynW  give  the  peculiar  and  characteristic  sense  of  pain  experienced  in  in- 
jury of  this  organ. 

In  neoplasms  there  is  a  history  of  progressive  development  entirely 
disassociated  from  that  of  hernia  as  heretofore  detailed. 

Abscess,  which  not  infreqixently  appears  above  Poupart's  ligament, 
is  accompanied  with  inflammatory  and  septic  symptoms  which  do  not 
accompany  hernia.  Abscess  of  this  region  occurs  with  adenitis,  as  just 
stated,  and  with  ostitis  of  the  vertebrae  or  ilium.  The  recognition  of 
either  of  these  lesions  wall  lead  to  the  diagnosis  of  abscess. 

In  the  manipulation  of  a  hernial  tumor  the  sensation  imparted  to  the 
fingers  will  vary  with  the  contents  of  the  sac  and  the  condition  of  the 
mass.  If  it  contain  only  omentum,  it  is  doughy  to  the  feel,  and  will 
yield  dullness  on  percussion  ;  if  the  mass  is  composed  of  intestine,  it  is 
elastic,  and  more  or  less  tympanitic  on  percussion.  The  "colicky" 
pain  felt  when  the  intestine  is  firmly  compressed  is  of  diagnostic  value 
in  determining  the  presence  of  a  hernia. 

Whether  a  hernia  is  reducible  or  not,  there  is  always  a  perceptible 
impulse  imparted  to  the  tumor  in  coughing  or  sneezing.  In  strangulated 
hernia  the  diagnosis  rests  first  upon  the  existence  of  a  tumor,  which  is 
present  in  almost  all  cases.  In  veiy  exceptional  instances  there  is  no  pro- 
trusion noticeable.  The  next  symptom  is  pain  at  the  seat  of  the  hernia. 
In  character  it  is  compared  to  that  of  intestinal  colic,  and,  when  not  in- 
tensified in  the  neighborhood  of  the  strangulation,  it  is  usually  referred  to 

35* 


55S  A  TEXT-BOOK   ON   SURGERY. 

the  umbilical  region.  The  symptoms  of  occlusion  are  more  remote,  and, 
while  very  strong  in  a  diagnostic  point  of  view,  are  not  of  such  impor- 
tance practically,  because  a  diagnosis  should  be  made  and  treatment  in- 
stituted before  the  effects  of  obstruction  are  made  evident.  The  cessation 
of  fecal  discharges  may  not  occur  in  intestinal  obstruction  for  several 
days  after  the  occlusion,  when  the  small  intestine  alone  is  involved,  since 
the  contents  of  the  bowel  below  the  constricted  point  may  be  evacuated. 
The  vomiting  of  recently  ingested  food  or  drinks,  followed  by  stercora- 
ceous  matter,  is  the  last  and  strongest  evidence  of  occlusion.  Distention 
of  the  abdominal  walls,  with  tympanitic  resonance,  is,  when  taken  in 
connection  with  other  symptoms,  a  strong  link  in  the  chain  of  symptoms 
which  make  the  diagnosis  conclusive.  Hiccough  is  present  in  many 
cases,  but  is  apt  to  be  one  of  the  later  evidences  of  obstruction.  Shock, 
that  condition  in  which,  as  a  result  of  an  emotion  or  injury,  the  functions 
of  the  nerve-centers  are  more  or  less  completely  suspended,  is  present  in 
a  varying  degree  in  almost  all  cases  of  strangulated  hernia.  It  is  evident 
in  the  rapid  and  weak  pulse,  occasionally  missing  a  beat,  or  varying  in 
exacerbations  of  rapidity  and  slowness ;  coldness  of  the  skin,  with  un- 
natural perspiration  ;  lack  of  facial  mobility,  the  only  expression  being 
that  of  pain  and  anxiety. 

In  omental  hernia  the  pain  is  not  so  intense  as  in  intestinal  hernia, 
and  the  symptoms  of  occlusion  are  always  absent. 

Treatment. — The  treatment  of  inguinal  hernia  may  be  considered 
under  the  following  heads :  1,  reducible ;  2,  irreducible  (not  strangu- 
lated) ;  3,  strangulated. 

For  a  hernia  not  strangulated,  the  operative  measures  are  palliative 
and  curative  ;  in  strangulated  hernia  early  operation  is  always  indicated. 

A  reducible  inguinal  hernia  should  be  returned  to  the  abdominal 
cavity  and  retained  there  by  the  constant  and  careful  employment  of  a 
truss  or  bandage  and  compress.  In  accomplishing  the  reduction  the 
patient  should  rest  upon  the  back,  with  the  thighs  flexed  upon  the  abdo- 
men and  the  pelvis  elevated.  In  this  position  gravity  carries  the  intes- 
tine and  omentum  toward  the  diaphragm,  and  this  traction  from  within 
readily  reduces  the  mass.  If  this  should  not  succeed,  gentle  pressure 
with  the  hand  will  suffice.  Once  reduced,  an  effort  should  be  made  to 
prevent  a  recurrence. 

For  incomplete  or  slight  hernia  in  patients  who  are  not  compelled 
to  do  heavy  work,  the  elastic  truss  is  most  comfortable  and  safe.  In 
all  other  cases  the  steel-spring  truss  must  be  woi^n.  The  pad  will  vary 
in  size  as  the  character  of  the  rupture  may  require.  The  hard-rubber 
or  wooden  pads  are  preferable  in  the  great  majority  of  cases.  A  truss 
should  be  applied  before  leaving  the  recumbent  posture,  and  should  not 
be  removed  again  until  this  posture  is  resumed.  When  ordering  a  steel- 
spring  truss  the  following  rule  should  be  observed :  Describe  fully  the 
character  of  the  hernia.  If  the  case  is  one  of  complete  oblique  inguinal 
hernia  of  the  left  side,  take  a  lead-tape,  lay  one  end  directly  over  the 
internal  ring  of  this  side  and  carry  the  tape  across  the  abdomen  to  the 
right,  just  below  the  anterior  superior  spine  of  the  i-ight  ilium,  and 


HERNIA.  559 

across  the  gluteal  region  back  to  tlie  same  point  below  the  left  superior 
spinous  process.  Press  the  malleable  lead  closely  to  the  integument  in 
order  to  get  an  exact  outline  of  the  surface  to  which  the  truss  is  to  be 
applied,  and  trace  this  directly  upon  a  sheet  of  paper.  The  instrument- 
malier  in  using  this  tracing  can  model  the  spring  to  fit  more  comfortably, 
and  after  this  temper  the  metal  to  make  the  requu-ed  pressure.  When  a 
direct  and  indii-ect  hernife  exist  uj)on  the  same  side,  a  single  pad  prop- 
erly adjusted  will  suffice  to  secure  both  openings.  When  there  exists  a 
bilateral  hernia,  a  double  truss  should  be  worn.  A  fair  temporary  truss 
may  be  made  as  foUows :  A  piece  of  cloth  or  a  tuft  of  wool,  cotton,  or 
oakum  is  rolled  into  a  compress  about  half  the  size  of  the  list,  covered 
with  adhesive  plaster  (the  adhesive  surface  being  external),  and  is  laid 
immediately  over  the  inguinal  canal,  after  the  hernia  has  been  reduced  ; 
while  the  patient  is  in  the  recumbent  posture  a  spica  bandage  is  car- 
ried around  the  pelvis  and  thigh  so  that  the  compress  is  held  firmly 
in  position.  It  is  prevented  from  slipping  out  of  place  by  the  adhesive 
plaster. 

When  an  inguinal  hernia  can  not  be  retained  by  a  trass,  operative 
interference  is  indicated.  In  cases  where  the  hernia  can  be  retained  and 
yet  interferes  with  the  usefulness  or  comfort  of  the  individual,  opera- 
tion for  radical  cure  is  also  advisable.  In  iiTeducible  hernia  which  inter- 
feres with  comfort  or  usefulness,  or  which  is  increasing  in  volume,  or  in 
persons  going  beyond  the  reach  of  proi:)er  surgical  aid.  opei^ation  for  the 
radical  cure  should  be  undertaken.  In  aged  persons  operation  should  be 
avoided,  unless  strangulation  is  occuiTing. 

Of  the  procedures  for  the  radical  cure  of  inguinal  hernia,  McBur- 
ney's  and  Macewen's  offer  the  best  prospects  of  success,  the  former 
being  preferable  on  account  of  its  gi'eater  simplicity  of  execution.  Both 
operations  are  yet  passing  through  a  period  of  probation,  yet  so  far  they 
have  given  results  which  justify  their  repetition. 

McBurney' s  Operation. — Under  strict  antisepsis  an  incision  is  made, 
beginning  a  little  outside  the  situation  of  the  internal  ring  and  extending 
well  down  over  the  tumor  in  the  direction  of  the  cord  and  deepened  until 
the  sac  is  exposed  (Fig.  544).  The  inter-columnar  fascia  having  been 
divided,  one  blade  of  a  blunt  scissors  is  pushed  under  the  edge  of  the 
external  ring,  and  the  anterior  wall  is  sj^lit  up  to  and  a  little  beyond  the 
outer  border  of  the  internal  ring  (Fig.  544  a).  The  deeper  coverings  of 
the  sac  are  dissected  off — preferably  with  the  fingers.  If,  now,  the  fascia 
transversalis  is  partially  removed  high  up  in  the  canal,  the  cord  may  be 
quite  easily  separated  from  the  sac  to  a  point  a  little  within  the  abdo- 
men. The  entire  sac  is  now  dissected  up  and  lifted  out  (Fig.  544b). 
(In  many  cases  of  congenital  hemise,  this  separation  can  not  be  effected, 
and  then  the  sac  must  be  cut  away  from  the  cord  at  each  side  of  the  lat- 
ter. When  this  is  done,  the  sac  requires  to  be  carefully  closed  by  cat- 
gut sutures.)  After  thorough  irrigation  and  cleansing  the  hands,  the 
sac  is  opened  and  the  intestine  reduced.  If  the  sac  contains  omentum, 
it  may  be  reduced  or  tied  off.  as  indicated  by  its  condition,  and  the 
stump  dropped  back.      Any  adhesions  are  broken  up  or  ligated  and 


560 


A  TEXT-BOOK   ON   SURGERY. 


Fig.  544. — The  hernial  mass  exposed  bv  a  free  incision.  The  dissection  carried  down  until  the  arch  of 
the  external  iufuinal  opening  is  seen,  with  its  outer  and  inner  pillar  on  either  side  of  the  hernia. 
The  lower  part  of  tho  sac  is  covered  by  the  inter-columnar  fascia.    (McBurney.) 


Fig.  544  a. — The  external  inguinal  ring  or  opening  divided  and  retracted,  together  with  the  aponeurosis 
of  the  external  oblique  muscle.     (McBurney.) 


FiQ.  544  b. — The  sac  with  hernial  contents  dissected  out,  and  the  necli  freed  to  the  level  of  the  parietal 
layer  of  the  peritoneum  and  turned  up  on  the  abdomen.     (McBurney. ) 


McBURNEY'S  OPERATION. 


561 


divided.  The  sac  is  now  held  vertically  (Fig.  544  c),  and  the  operator 
inserts  one  or  two  fingers  through  the  neck  into  the  peritoneal  cavity. 
This  is  done  to  guard  against  the  possible  return  of  a  loop  of  intestine 
or  omentum  into  the  sac  during  the  application  of  the  ligature.  While 
the  operator's  finger  is  still  in  this  position,  an  assistant  throws  a  loop 
of  very  strong  catgut  around  the  sac,  slips  it  along  the  neck,  gradu- 
ally tightens  and  finally  ties  it  over  the  tip  of  the  finger  at  the  very 


Fig.  544  c— Sao  opened,  contents  Tediiced,  finger  deeply  inserted,  and  the  neck  of  the  sao  tied  off  at  the 
level  of  tlie  internal  surface  of  the  abdominal  wall.     (McBurney.) 

deepest  portion  of  the  canal  (Fig.  544  c).  The  sac  outside  this  ligature 
is  cut  away,  leaving  enough  to  securely  prevent  the  ligature  from  slip- 
ping. The  ends  of  the  ligature  are  now  cut  away.  The  wound  which 
remains  has  for  its  posterior  wall  the  fascia  transversalis  in  its  inner 
part,  and  the  peritonaeum  in  its  outer  part.  The  upper  or  internal  wall 
is  formed  by  the  edges  of  the  skin,  superficial  fascia,  external  oblique 
aponeurosis,  and  conjoined  tendon ;  the  lower  wall  by  skin,  superficial 
fascia,  and  a  strip  of  aponeurosis, 
or  practically  Poupart's  ligament,  „-*«&- 

including  the  outer  pillar.  /  " 

In  order  to  prevent  too  rapid 
closure  of  the  wound  immediately 
over  the  internal  ring,  the  skin  is 
tucked  under  along  each  edge  of 
the  incision,  by  inserting  from  four 
to  eight  stout  silk  sutures  a  half- 
inch  apart,  so  as  to  include  all  the 
tissues  except  the  peritoneum.  They  enter  about  a  half-inch  from  the 
edge  of  the  wound,  and  as  they  are  tightened  the  skin  is  folded  under 
or  inverted  (Fig.  544  d). 


Fig.  544  d. — Showinf;  the  lower  portion  of  the  wound 
closed,  and  the  skin  tucked  under  to  maintain 
the  upper  portion  open.     (McBurnuy.) 


562 


A  TEXT-BOOK   ON   SURGERY. 


Fig.  544  e. — Supporting  sutures.     (McBumoy.) 


Two  tension  sutures  (Fig.  544  e)  are  next  inserted  through  the  skin 
and  superficial  fascia,  and  tied  over  rolls  of  iodoform  gauze  until  the 
edges  of  the  wound  are  about  one  fourth  of  an  inch  apart.  The  wound 
in  the  scrotum  is  stitched  with  catgut  and  a  drain  may  be  inserted  at  the 

lower  angle  if  deemed  necessa- 
ry. The  wound  is  now  deej)ly 
and  tightly  packed  with  iodo- 
form gauze,  over  this  masses 
of  sublimate  or  carbolic  gauze 
and  borated  cotton,  and  over 
all  a  spica  bandage.  A  piece 
of  rubber  tissue  should  be 
placed  around  the  penis  and 
superficial  to  the  dressing,  to  prevent  the  possible  infect-ion  of  the  wound 
by  the  urine.  The  catheter  may  be  employed  for  the  first  few  days. 
In  children,  it  is  advisable  to  envelope  the  thighs  and  pelvis  in  plaster- 
of-Paris  to  prevent  movements  in  bed.  The  dressing  should  be  changed 
from  the  sixth  to  the  twelfth  day,  and  every  four  to  six  days  after  this. 
The  silk  threads  may  be  removed  about  the  tenth  or  twelfth  day.  The 
dorsal  decubitus  should  be  maintained  for  five  or  six  weeks.  A  spica 
may  be  worn  for  a  week  or  two  after  this  and  then  discarded.  Ko  truss 
should  be  worn  after  the  spica  is  removed.* 

It  will  be  seen  that  the  object  of  this  procedure  is,  1,  to  tie  off  the  sac 
at  the  level  of  the  parietal  peritonaeum,  thus  obliterating  any  funnel- 
shaped  process  which  might  invite  the  reformation  of  a  hernia  ;  2, 
to  comijel  in  the  j)rocess  of  repair  the  formation  of  a  deep  cicatrix 
which  will  obliterate  in  great  part  the  old  canal,  and  also  strengthen 
the  otherwise  over-stretched  and  weakened  structures  about  the  ingui- 
nal canal. 

In  incomplete  hernia,  where  the  sac  is  so  short  that  it  can  not  be  tied, 
it  is  more  than  likely  a  cure  would  result  from  the  cicatricial  contraction 
secured  by  the  operation.     I  have  not  found  it  necessary  to  insert  the 
tucking  or  supporting  sutures  recommended  by  McBurney, 
but  keep  the  wound  open  by  careful  packing  with  the  gauze. 


Fio.  544  F. — Macewen'3  richt  and  left  needles,  used  in  operations  for  the  radicil 
cure  of"in2;uinal  hernia.     (After  Macewen.) 


Macewen' s  Operation. — This  operation  is  intended  for  the  cure  of 
oblique  inguinal  hernia.  The  preparation  is  the  same  as  that  just  given, 
and  strict  asepsis  is  necessary.     Macewen  advises  the  emplpyment  of  a 


*  "  Medical  Record,"  March,  1889. 


MACEWEN'S   OPERATION. 


563 


right  and  left  needle  (Fig.  544  f).  The  ordinary  Hagedorn  needle  may 
be  substituted.  The  incision  and  steps  of  the  operation  are  practically 
the  same  as  for  McBurney's  proced- 
ure down  to  the  reduction  of  the  her- 
nia. Macewen  advises  the  reduction 
of  the  contents  of  the  sac  before  the 
first  incision  is  made  ;  but  the  separa- 
tion of  the  sac  from  the  investing  fas- 
cia is  more  easily  accomj)lished  when 
it  is  distended  by  the  hernia.  The 
external  abdominal  ring  being  well 
exposed,  an  exploration  of  the  sac 
is  made,  and  the  finger,  introduced 
through  the  canal,  examines  the  ab- 
dominal aspects  of  the  internal  ring 
and  ascertains  the  relative  position  of 
the  epigastric  artery.  Now  free  and 
elevate  the  distal  extremity  of  the  sac, 
preserving  along  with  it  any  adipose 
tissue  that  may  be  adherent  to  it. 
When  this  is  done,  pull  down  the  sac, 
and,  while  maintaining  tension  upon 
it,  introduce  the  index-finger  into  the 
inguinal  canal  (outside  the  sac),  and 
separate  the  sac  from  the  cord  and  the 
parietes  of  the  canal. 

Insert  the  index-finger  outside  the  sac  till  it  reaches  the  internal 
ring  ;   then  separate  with  its  tip 
the  peritonfEum  for  about  a  half 
inch  round  the  whole  abdominal 
aspects  of   the  circumference  of 

the  ring  (Fig.  544  g). 

A    large-sized   cat- 
gut suture  is  now 

carried  through  the 

distal  extremity  of 

the  sac  and  passed 

in  and  out  several 

times  through  both 

walls    and    finally 

through    the    neck 

of  the  sac,  so  that 

when  pulled  upon 
the  sac  becomes  puckered  and 
folded  on  itself,  as  shown  in  Fig. 
544  H.  The  free  end  of  this  sut- 
wre  is  now  threaded  on  one  of  „     .      ,    ^,..        .      ^      i  ti 

Fig,  544 1.— Carrying  the  folding  suture  through  the 
the    needles    (or  an  ordinary  hall-  abdommal  wall.     (After  Macewen.) 


Fig.  544  g. — Separating  the  peritoneum  from  the 
abdominal  wall  around  the  neck  of  the  sac. 
(After  Macewen.) 


Fig.  544  n. 
Folding  tlie  sac. 
(After  Macewen.) 


564 


A  TEXT-BOOK   ON   SURGERY. 


curved  Hagedorn  needle  may  be  substituted),  which  is  inserted  by  the 
side  of  the  neck  of  the  sac  between  the  parietal  reflection  of  the  perito- 
nseum  and  the  muscles,  and  made  to  penetrate  the  anterior  abdominal 
wall  about  one  inch  above  the  internal  ring  (Fig.  544 1),  the  wound  in 
the  skin  being  pulled  upward  so  as  to  allow  the  point 
of  the  needle  to  project  through  the  abdominal  mus- 
cles without  penetrating  the  skin.  Traction  upon  the 
suture  throws  the  sac  into  a  series  of  wrinkles  or 
folds,  and  pulls  it  en  masse  into  the  internal  ring, 
where  it  projects  on  the  internal  aspect  of  the  ab- 
dominal wall  (Fig.  544  j).  An  assistant  maintains 
steady  traction  upon  this  until  the  stitches  are  passed 
to  close  the  inguinal  canal,  when  its  free  extremity 
should  be  several  times  passed  through  the  sujjer- 
ficial  layers  of  the  external  oblique  muscle  in  order 
to  secure  it ;  or  it  may  be  tied  to  a  piece  of  decalci- 
fied bone  drainage-tube. 
The  method  of  treating  the  sac  may  be  modified  by  carrying  the 
suture  after  it  is  inserted  into  the  distal  end  of  the  sac  directly  into  the 
canal  and  through  the  abdominal  wall.  The  sac  is  drawn  in  but  not 
puckered.     Macewen  thinks  this  may  suflBce  in  children. 

The  second  step  in  this  operation  is  the  closure  of  the  inguinal  canal. 
The  sac  being  in  the  position  just  described,  the  string  firmly  held  by  an 
assistant,  the  finger  is  introduced  into  the  canal  and  is  held  between  the 
inner  and  lower  borders  of  the  internal  ring,  finding  the  epigastric 
artery  so  as  to  avoid  it.     The  hernia  needle,  threaded  for  this  part  of  the 


Fig.  544  j. — Showing  the 
sac  folded  up  and  cov- 
ering the  abdominal  oa- 
pectoftlie internal  ling. 
(Alter  Macewen.) 


Fic.  544  K. — Inserting  the  sutures  through  the 
conjoint  tendon.     (After  Macewen.) 


Fig.  544  l. — Sutures  ready  for  tying. 
(Alter  Macewen.) 


STRANGULATED   INGUINAL   HERNIA.  565 

operation  with  a  very  strong  chromic-acid  catgut  suture,  is  now  intro- 
duced and,  guided  by  the  index-finger,  is  made  to  penetrate  the  conjoint 
tendon  in  two  places :  first,  from  witliout  inward  near  the  lower  border 
of  the  conjoint  tendon,  and  then  from  within  outward  as  high  as  possi- 
ble on  the  inner  aspects  of  the  canal  (Fig.  544  k). 

The  lower  end  of  this  loop  is  again  threaded  into  the  proper  needle 
and  passed  through  Poupart's  ligament  and  the  aponeurotic  structures 
of  the  transversalis,  internal  and  external  oblique  muscles,  penetrating 
those  tissues  on  a  level  with  the  lower  stitch  in  the  conjoint  tendon. 
The  upper  end  of  the  suture  is  also  brought  through  the  same  structures 
at  its  level  (Fig.  544  l). 

The  two  free  ends  are  now  tied  in  a  reef-knot,  which  finally  closes  the 
canal.  The  wound  is  closed  with  catgut  sutures,  bone-drain,  strict  anti- 
septic dressing,  which  is  left  on  from  fourteen  to  twenty-one  days  and 
reapplied.  The  patient  is  not  allowed  to 
leave  the  dorsal  decubitus  for  four  to  six 
weeks,  nor  to  work  until  the  eighth  week, 
and  not  to  do  any  lifting  or  heavy  work 
for  three  months. 

In  congenital  hernia  the  sac  is  first 
isolated  from  the  canal,  opened  and  cut 
in  two,  care  being  taken  to  preserve  the     fig.  544  M.-Manner  of  treating  the  sae 
cord    (Fig.    544  m).      The    lower  part    is  iSaTe^^en"'^ '°^"'°''' ^'™''''   ''^^'' 

closed  to  form  a  tunica  vaginalis  ;  the 

upper  is  pulled  down  as  far  as  possible,  split  behind  longitudinally  so 
as  to  allow  the  cord  to  escape,  and  then  closed  by  sutures  and  treated 
exactly  as  for  acquired  hernia. 

In  competent  hands  and  in  well-selected  cases  in  both  of  these  pro- 
cedures the  danger  is  reduced  to  the  minimum,  and  the  prospects  of  cure 
are  very  good.  Both  are  operations  through  open  wounds.  McBurney's 
method  has  the  greater  advantage  of  simplicity.  The  chief  point  in  it 
is  to  tie  the  sac  off  at  the  level  of  the  abdominal  peritonfeum.  Another 
advantage  of  this  procedure  is  the  more  thorough  cicatrization  secured, 
and  in  this,  I  believe,  the  operation  depends  chiefly  for  success.  It  will, 
in  my  opinion,  be  found  the  superior  method  for  a  large  proportion  of 
cases.  In  unusually  large  hernise  an  advantage  might  be  gained  by 
puckering  the  sac,  as  advised  by  Macewen,  and  treating  the  wound  after 
McBurney. 

Strangulated  Inguinal  Hernia. — With  the  first  symptom  of  strangu- 
lation the  patient  should  be  placed  in  the  dorsal  decubitus,  with  the  foot 
of  the  bed  elevated  about  twelve  inches,  the  pelvis  raised  upon  a  pillow, 
the  legs  flexed  on  the  thighs,  and  the  thighs  on  the  abdomen,  so  that  the 
intestines  and  omentum  will  gravitate  toward  the  diaphragm  ;  or  the 
knee-shoulder  position  may  be  assumed.  Opium  narcosis  should  be 
secured  at  once  to  relieve  pain  and  to  relax  the  muscles  of  the  abdo- 
men. Towels  dipped  in  hot  water  and  partially  squeezed  should  be 
laid  upon  the  tumor.  If  within  an  hour  or  two  the  hernia  is  not  re- 
duced, direct  and  careful  pressure  with  the  fingers  may  be  added.     The 


566  A  TEXT-BOOK   ON  SURGERY. 

neck  of  the  tumor  should  be  grasped  and  steadied  between  the  thumb 
and  fingers  of  one  hand,  and  the  contents  pushed  gently  in  the  direc- 
tion of  the  canal  with  the  other.  Taxis  should  not  be  continued  longer 
than  five  or  ten  minutes  at  any  one  effort.  It  may  be  repeated  at  in- 
tervals of  a  half-hour  or  hour  within  the  first  six  hours  of  the  his- 
tory of  strangulation.  The  manipulation  of  a  hernial  tumor  (taxis)  after 
the  first  six  hours  of  strangulation  is  of  doubtful  propriety,  and  after 
twelve  hours  should  not  be  attempted.  It  is  not  only  to  be  condemned 
for  the  injury  inflicted  upon  the  parts  involved  by  this  procedure,  but 
on  account  of  the  procrastination  in  operative  interference  which  it 
invites.  It  is  true  that  occasionally  reduction  is  effected  after  symp- 
toms of  strangulation  lasting  for  a  longer  period  than  this,  but  these 
cases  are  so  extremely  rare,  and  the  danger  of  a  fatal  termination  so 
much  increased  by  the  delay,  that  it  will  be  wiser  to  proceed  at  once  to 
the  operation. 

In  justification  of  early  operation,  it  may  be  said  that  the  large  ma- 
jority of  cases  which  end  fatally  are  those  in  which  strangulation  has 
existed  for  from  twelve  to  twenty-four  hours  and  upward  before  surgical 
interference  ;  and  that  abdominal  section  in  a  patient  not  exhausted  by 
suffering  or  disease  is  almost  free  from  danger.  The  high  rate  of  mor- 
tality after  kelotomy  will  only  be  materially  reduced  when  it  is  per- 
formed not  later  than  twelve  hours,  and,  better  still,  within  the  first  six 
hours  of  strangulation. 

Operation. — The  pubes,  scrotum,  and  integument  near  the  tumor 
should  be  shaved,  washed  with  ether,  and  finally  with  l-to-3000  subli- 
mate solution.  The  patient,  fully  aneesthetized,  should  be  placed  upon 
a  table  nearest  the  edge  most  convenient  to  the  operator,  with  the  pelvis 
slightly  elevated.  Before  proceeding  with  the  operation,  a  final  effort  at 
reduction  should  be  made.  An  assistant  is  directed  to  place  the  legs  of 
the  patient  over  his  shoulders,  and  to  lift  him  until  nothing  but  the 
shoulders  and  occiput  rest  upon  the  table.  While  in  this  position  care- 
ful taxis  should  be  made.  If,  after  five  minutes,  reduction  is  not 
effected,  the  attempt  should  be  abandoned.  The  parts  about  the  field  of 
operation  should  be  covered  with  warm  sublimate  towels  (l-to-3000),  leav- 
ing a  space  about  six  by  eight  inches  uncovered. 

The  incision  should  be  in  the  long  axis  of  the  tumor,  and  may  be 
made  by  cutting  directly  down  upon  the  mass,  or  by  pinching  u]3  the 
skin  and  fat  immediately  over  the  swelling,  transfixing  it  and  cutting 
outward.  It  should  be  of  good  length,  with  the  center  a  little  below  the 
internal  ring.  All  bleeding  should  be  arrested  at  once  with  catgut  liga- 
tiires.  The  wound  should  be  irrigated  with  l-to-5000  sublimate  every 
five  or  ten  minutes. 

The  first  difficult  point  in  the  operation  is  the  recognition  of  the  sac. 
It  is  safe  to  cut  carefully  down  until  through  the  puncture  of  the  sac  a 
yellow  or  brownish-black  fluid  escapes.  It  is  very  excej^tional  when 
there  is  not  enough  fluid  between  the  hernia  and  the  sac  to  demonstrate 
its  presence.  If  adhesions  of  the  sac  to  its  contents  have  taken  place,  no 
fluid  would  be  encountered.     Such  a  complication  is  rarely  met  with. 


STRANGULATED   INGUINAL   HERNIA. 


567 


When  this  fluid  begins  to  escape,  a  grooved  director,  with  a  very  dull 
point,  is  inserted  through  the  puncture,  and  the  sac  further  divided 
until  the  finger  can  be  admitted,  when  it  is  introduced  and  the  sac  di- 
vided in  the  entire  extent  of  the  tumor.  At  this  stage  of  the  operation 
the  contents  of  the  sac  are  clearly  in  view.  A  thorough  irrigation  should 
now  be  made,  and  the  hands  of  the  oiaerator  carefully  cleansed.  The 
finger  of  the  left  hand  is  carried  toward  the  constriction,  palmar  sur- 
face upward,  and  the  nail  slipped  under  it.     Holding  the  intestine  out 


Fig.  545. — Showing  the  relations  of  a  direct  inguinal  hernia  to  the  epigastric  vessels  imd  the  apermatio 
cord.  1,  Hernial  tumor.  2,  Epigastric  vessels  in  front  of  and  external  to  the  neck  of  the  tumor. 
3,  Saphenous  opening  and  vein.    4,  Spermatic  vessels.     5,  Femoral  vessels.     6,  Crural  nerve. 


of  the  way,  a  long,  probe-pointed  bistoury  is  carried  flatwise  along  the 
palmar  aspect  of  the  finger  until  the  dulled  point  passes  between  the 
sharp  edge  of  the  ring  and  the  nail.  The  edge  is  now  turned  upward 
against  the  ring,  and  pressed  against  this  by  the  finger  upon  which  it 
rests.  The  direction  of  this  cut  is  upward  and  very  slightly  inward 
in  inguinal  hernia.  It  should  not  extend  beyond  the  eighth  of  an  inch. 
The  finger-nail  is  usually  sufiicient  to  enlarge  the  opening  after  the  first 
few  fibers  are  divided. 


568 


A  TEXT-BOOK  ON  SURGERY. 


As  soon  as  the  strangulation  is  relieved,  the  wound  and  exposed  intes- 
tine should  be  covered  in  with  towels  dipped  in  warm  Thiersch  solution, 
and  left  for  from  five  to  fifteen  minutes  in  order  to  determine  whether 
the  circulation  can  be  re-established  or  not.  The  color  of  strangulated 
intestine  varies  from  pinkish-gray  to  a  black,  motley  color.  The  con- 
tents of  a  hernial  sac  should  not  be  returned  into  the  abdomen  unless 
the  color  changes  to  a  healthy  red  after  the  strangulation  is  freely  re- 
lieved. If,  after  from  five  to  twenty  minutes,  the  circulation  is  estab- 
lished, reduction  should  be  made.     In  accomplishing  this,  posture  is 


t.        ^/   V=S=-SL 


Fig.  540. — Showing  the  relations  of  an  oblique  inguinal  hernia.  1,  Tumor  covered  by  cremasteric  fascia. 
2,  Epigastric  vessels  behind  and  to  the  inner  side  of  the  neck  of  the  tumor. .  3,  Saphenous  vein  and 
opening.     4,  Femoral  vessels.     6,  Crural  nerve. 


important,  and  the  intestine  should  be  carefully  pushed  in  between  the 
thumb  and  finger.  Once  returned,  the  inner  opening  should  be  stopped 
with  the  finger  or  a  sponge  secured  by  a  string  or  holder  so  that  blood  or 
the  contents  of  the  sac  or  irrigating  fluid  may  not  run  into  the  peritoneal 
cavity.  Sublimate  solution  should  be  discontinued  after  the  hernia  is 
reduced  and  Thiersch's  solution  used.  If  omentum  is  contained  in  the 
hernia,  it  should  be  transfixed  at  the  neck  of  the  sac  with  a  large  double 
catgut  ligature,  tied  both  ways,  and  the  mass  beyond  the  ligature  cut 


STRANGULATED  IISTGUINAL  HERNIA.  569 

off.  The  stump  should  also  be  returned  into  the  cavity.  The  details  of 
McBurney's  operation,  should  now  be  carried  out,  in  the  hope  of  effecting 
a  radical  cure. 

In  case  the  intestinal  wall  is  broken  down,  or  is  so  nearly  necrotic 
that  its  return  into  the  cavity  of  the  abdomen  is  attended  with  danger 
of  rupture  of  the  gut  and  escape  of  its  contents,  two  alternatives  present 
themselves,  viz. :  to  leave  the  intestine  protruding,  and  establish  an  arti- 
ficial anus  ;  or  to  exsect  the  dead  portion  and  sew  the  ends  together.  If 
the  patient  is  in  good  condition,  and  especially  if  in  the  prime  of  life  and 
usefulness,  exsection  should  be  done.  If,  on  the  other  hand,  collapse  is 
imminent,  or  if  there  is  anything  in  the  condition  of  the  patient  to  contra- 
indicate  a  prolonged  operation,  the  fecal  fistula  should  be  established. 

Immediate  exsection  is  performed  as  follows :  Eelease  the  strangula- 
tion as  above  described,  and  draw  out  both  ends  of  the  bowel  until  six  or 
eight  inches  of  sound  gut  are  exposed.  Place  a  clamp  or  throw  a  loop  of 
disinfected  tape  around  each  end  of  the  intestine  near  the  ring,  to  pre- 
vent the  possibility  of  retraction  or  escape  of  the  bowel  or  its  contents 
inward.  With  sharp  scissors  divide  the  intestine  squarely  across  at  each 
end  of  the  limit  of  necrosis,  and  cut  a  triangular  piece  from  the  mesen- 
tery, the  base  of  w^hich  corresponds  exactly  to  the  section  of  intestine 
removed.  Ligate  all  bleeding  points  in  the  mesentery.  The  operation  is 
completed  in  the  same  manner  as  in  exsection  of  the  intestine,  given  on  a 
preceding  page.* 

The  question  of  preference  between  terminal  anastomosis  and  lateral 
anastomosis  by  means  of  the  Senn  or  Abbe  rings,  as  heretofore  discussed, 
may  also  be  applied  to  this  operation.  If  the  operator  is  expert  and 
safely  rapid,  or  if  the  patient  is  in  good  condition,  uniting  the  ends  di- 
rectly to  each  other  is  preferable. 

When  it  is  desired  to  establish  an  artificial  anus,  the  strangulation 
should  be  relieved  as  already  directed,  and  the  bowel  incised.  As  a 
rule,  it  is  not  necessary  to  stitch  the  gut  to  the  wound,  on  account  of 
the  adhesions  which  usually  exist. 

In  the  course  of  a  few  weeks,  after  the  patient  has  fully  recovered 
from  the  effects  of  the  strangulation  and  the  oi^eration,  the  canal  may  be 
restored,  by  opening  the  abdomen,  exsecting  the  protruding  and  attached 
portion  of  intestine,  and  uniting  the  ends  by  stitches  (p.  539).  Or  the 
operation  of  Dupuytren  may  be  undertaken.  It  consists  in  gradually 
breaking  down  the  promontory  formed  by  the  contiguous  walls  of  the 
incarcerated  loop,  and,  when  this  is  done,  allowing  the  external  wound 
to  close  by  granulation.  The  instrument  used  in  this  operation  is,  in 
shape,  not  unlike  a  pair  of  forceps,  with  flat,  roughened  jaws,  and  long 
handles,-  which  can  be  locked  with  a  clamp.  The  jaws  are  introduced  at 
first  for  a  slight  distance  only,  one  going  into  the  ascending  and  the 
other  into  the  descending  part  of  the  loop  of  intestine,  when  they  are 

*  This  operation  of  immediate  exsection — i.  e.,  exsection  through  the  hernial  opening — has 
been  frequently  and  successfully  performed  in  late  years,  notably  by  Dawbarn,  who  exsected 
about  twelve  inches  of  the  ileum;  MoCosh  also,  of  New  York,  and  Stewart,  of  Minneapolis,  who 
operated  while  Honse-Surgeon  at  Mount  Sinai  Uospital. 


570 


A  TEXT-BOOK  ON  SURGERY. 


closed  and  clamped  in  such  a  manner  that  the  walls  of  the  promontory 
are  held  firmly  in  contact  (Fig.  547).  The  instrument  is  allowed  to  re- 
main in  position.  Adhesion  occurs  in  the  contiguous  peritoneal  cover- 
ings of  the  gut,  while  that  part  of  the  promontory  firmly  grasped  by 

the  instrument  is  crushed  or  sloughs 
away.  As  soon  as  the  projection  is 
sufficiently  broken  down,  the  fistulous 
opening  may  be  allowed  to  close. 

This  procedure  has  been  successful 
in  a  number  of  cases  sufficient  to  jus- 
tify its  employment.  If  a  cure  is  not 
effected,  or  if  stricture  should  result, 
exsection  should  be  performed. 

Inguinal  hernia  in  the  female  has 
the  same  relation  to  the  epigastric  ves- 
sels as  in  the  male  subject.  In  the 
complete  form  the  contents  may  de- 
scend into  the  labium.  The  treatment 
does  not  differ  materially  from  that 
Just  given.  Cysts  of  the  canal  of  Niick 
not  infrequently  simulate  a  hernial  tu- 
mor. Occasionally  the  ovary  descends 
into  the  canal. 

Femoral  Hernia —  Treatment.  — This 
.  form  of  hernia  is  more  difficult  to  re- 
tain in  place  with  a  truss,  and  is  more  likely  to  become  incarcerated 
and  strangulated  than  any  other  variety.  The  prognosis  is,  therefore, 
more  unfavorable.  The  diagncsis  depends  upon  the  presence  of  a  tumor 
in  the  location  ah-eady  given  (Fig.  540),  the  neck  of  which  can  be  traced 
to  an  opening  at  the  inner  side  of  the  thigh.  Just  external  to  the  spine  of 
the  pubes,  and  below  Poupart's  ligament.  The  impulse  in  coughing  is 
present,  though  usually  less  perceptible  than  in  inguinal  hernia.  Cysts 
are  less  apt  to  complicate  a  femoral  than  an  inguinal  hernia.  Enlarge- 
ment of  the  lymphatic  glands  will  not  be  apt  to  mislead,  since  there  will 
have  been  a  history  of  adenitis,  a  gradual  increase  in  the  size  of  the 
glands,  which  may  be  recognized  as  a  group.  The  absence  of  impulse 
with  the  act  of  coughing  will  further  aid  in  the  exclusion  of  hernia. 

The  symptoms  of  strangulation  differ  in  no  essential  features  from 
those  in  inguinal  hernia. 

Treatment. — A  reducible  femoral  hernia  should  be  retained  within 
the  abdomen  by  a  truss,  the  pad  of  which  presses  firmly  over  the  femoral 
ring.  Just  external  to  the  spine  of  the  pubes.  The  pad  should  be  small, 
so  that  it  may  not  com]3ress  the  femoral  vein,  and  the  spring  should  be 
strong,  for  this  form  of  hernia  is  not  only  difficult  to  retain,  but  is  doubly 
dangerous  when  it  escapes  by  the  side  of  the  pad. 

In  reducing  femoral  hernia,  position  is  invaluable,  and  taxis  may  be 
of  aid.  The  best  position  without  taxis  is  the  knee-shoulder  posture,  in 
which  the  abdominal  muscles  and  fascia  lata  are  relaxed,  and  the  contents 


Fig.  547.— Dupuytren's  clamp. 
(After  Gross.) 


FEMORAL  HERNIA.  57I 

of  the  abdomen  gravitate  toward  the  diaphragm.  Or  the  dorsal  decubitus 
may  suflBce,  with  the  pelvis  elevated,  as  well  as  the  foot  of  the  bed,  and 
the  thighs  flexed  upon  the  abdomen.  In  performing  taxis  it  must  be 
remembered  that  the  bulk  of  the  hernia  must  pass  directly  backward  to 
clear  the  falciform  process  of  the  fascia  lata,  and  then  upward  in  the 
direction  of  the  femoral  canal  (Fig.  540).  Operation  for  the  radical 
cure  of  femoral  hernia  may  be  determined  by  the  rules  given  for  the  in- 
guinal variety,  and,  while  the  prospects  of  success  may  not  be  so  good, 
the  principles  of  McBurney's  procedure  may  be  here  applied. 

In  irreducible  (not  strangulated)  femoral  hernia  operative  interference 
is  more  positively  indicated,  from  the  fact  that  strangulation  is  more  apt 
to  occur,  and  that  the  employment  of  a  compress  to  prevent  a  further 
descent  of  the  mass  is  rarely  successful. 

In  strangulated  femoral  hernia  operative  interference  is  indicated 
immediately  upon  the  first  symptoms  of  this  condition.  So  rapid  are 
the  changes  which  occur  in  the  contents  of  the  sac  that  early  operation, 
always  commendable  in  every  form  of  strangulated  hernia,  is  especially 
so  in  the  variety  under  consideration.  Taxis  should  not  be  performed 
until  the  patient  is  fully  anaesthetized.  The  preparation  for  the  opera- 
tion is  identical  with  that  for  inguinal  hernia.  When  narcosis  is  com- 
plete, the  patient  should  be  lifted  by  the  legs  in  such  a  way  that  the 
thighs  will  be  flexed  upon  the  abdomen,  and  the  pelvis  raised  consider- 
ably higher  than  the  thorax.  While  in  this  position  taxis,  in  a  direction 
at  first  slightly  backward  and  then  upward,  should  be  practiced.  If 
reduction  is  not  effected  in  from  five  to  ten  minutes,  it  should  be  discon- 
tinued. 

The  incision  should  be  vertical  in  direction,  along  the  middle  of  the 
tumor,  with  its  center  over  the  femoral  ring.  The  length  will  vary  with 
the  size  of  the  protrusion,  but  three  or  four  inches  will  usually  suflice. 
It  should  be  made  by  cutting  directly  down  upon  the  sac,  and,  when  this 
is  reached,  the  dissection  should  be  continued  between  two  dissecting- 
forceps.  When  the  sac  is  opened  and  the  fluid  escapes,  the  index-finger 
should  be  introduced  and  carried  upward  until  the  end  iDasses  beneath 
the  falciform  process,  and  the  nail  is  under  the  sharp  constricting  edge 
of  Gimbernat's  ligament.  At  this  stage  of  the  operation  the  hernia  must 
be  kept  between  the  finger  and  the  femoral  vein,  and  the  edge  of  the  nail 
against  Gimbernat's  ligament,  just  at  its  insertion  at  the  os  pubis.  A 
long,  probe-pointed  knife  is  now  carried  flatwise  along  the  palmar  side  of 
the  finger,  with  the  cutting  edge  directed  toward  the  median  line.  The 
constriction  is  relieved  by  lifting  or  scraping  the  attachment  of  Gimber- 
nat's ligament  from  the  os  pubis,  and  in  doing  this  the  cutting  edge  of 
the  knife  should  not  be  carried  beyond  this  ligament,  nor  should  it  have 
any  other  direction  than  inward  toward  the  symphysis.  If  these  precau- 
tions are  not  observed,  a  dangerous  complication  may  arise  in  the  division 
of  the  obturator  artery  (or  vein),  in  cases  in  which  it  is  derived  from  the 
epigastric  branch  of  the  external  iliac.  In  eight  fatal  cases  of  this  char- 
acter the  patients  were  females.  This  abnormal  derivation  occurs  in 
women  in  nearly  50  per  cent  of  cases,  and  in  25  per  cent  in  men,  while 


572  A  TEXT-BOOK   ON   SURGERY. 

the  vein  is  in  relation  to  the  femoral  ring  in  a  larger  proportion  of  cases.* 
The  manner  in  which  the  artery  arches  over  the  crural  ring  is  shown  in 
Fig.  539.  "When  the  strangulation  is  released,  and  the  contents  of  the 
sac  returned  into  the  abdomen,  an  effort  should  be  made  to  effect  a  radi- 
cal cure  as  above  directed. 

Uvibilical  Hernia. — The  diagnosis  between  this  form  of  hernia  and 
other  tumors  of  the  umbilical  region  will  depend  chiefly  upon  the  im- 
pulse conveyed  to  the  hernia  in  the  act  of  coughing,  or  in  crying  in 
children.  If  the  hernia  is  made  up  of  omentum — and  this  is  not  un- 
common in  adults — it  will  be  doughy  to  the  feel  and  flat  or  dull  on  per- 
cussion. Intestine  will  be  more  or  less  resonant  on  percussion.  If  the 
mass  is  reducible  in  the  recumbent  posture,  and  under  direct  manipula- 
tion the  diagnosis  of  hernia  is  evident.  Cyst  of  the  omphalo-mesenteric 
duct  would  be  translucent,  and  fluctuation  would  be  present.  In  con- 
genital hernia  the  extreme  thinness  of  the  covering  renders  the  recog- 
nition of  the  character  of  the  tumor  easy. 

Treatment. — When  an  umbilical  hernia  which  is  only  covered  by  the 
thin  membrane  of  the  cord  exists  at  birth,  it  should  be  returned  at  once, 
and  the  opening  closed  by  carefully  adjusted  silk  sutures,  supjiorted  by 
adhesive  strips,  drawn  in  dovetail  fashion  across  the  abdomen  at  the 
weak  point.  If  covered  over  with  integument,  it  should  be  reduced,  a 
small,  Arm  compress  placed  in  the  opening,  and  secured  in  place  by  a 
band  of  adhesive  plaster  carried  around  the  child's  belly.  The  acquired 
form  is  treated  in  the  same  general  way.  It  should  be  reduced  by  post- 
ure, aided  by  careful  taxis  if  necessary,  and  a  truss  worn  day  and  night. 
In  mild  cases  a  light  rubber  belt  will  suffice  after  retiring  for  the  night, 
but  the  heavier  apparatus  should  be  adjusted  before  leaving  the  recum- 
bent posture. 

Irreducible  hernia,  not  strangulated,  may  be  held  in  iiosition  by  a 
properly  adjusted  cup-shaped  compress. 

The  danger  of  strangulation  is  always  present,  and  the  question  of 
the  advisability  of  operating  to  relieve  the  incarceration,  and  of  sewing 
up  the  opening,  must  be  determined  by  the  circumstances  of  each  par- 
ticular case.  In  the  operation  for  radical  cure  the  sac  should  be  tied  off 
or  cut  away  and  the  wound  closed  with  strong  silk  sutures.  These  su- 
tures should  include  all  the  tissues  of  the  abdominal  wall,  so  that  when 
tightened  the  apposing  surfaces  of  the  parietal  peritonaeum  of  the  two 
edges  will  be  united. 

With  the  first  symptoms  of  strangulation  the  patient  should  be 
etherized,  and  a  final  effort  at  reduction  made  by  careful  taxis.  If  this 
does  not  succeed,  kelotomy  should  be  at  once  performed.  The  incision 
should  be  vertical,  with  its  center  corresponding  to  the  neck  of  the  her- 
nia. On  account  of  the  exceeding  thinness  of  the  integument  and  other 
coverings,  great  care  should  be  exercised  in  cutting  down  upon  the 
tumor.     As  soon  as  the  sac  is  punctured,  the  dull  director  is  introduced, 

*  The  author's  "  Essays  in  Surgical  Anatomy  and  Surgery."  William  Wood  &  Co.,  1878. 
"  New  York  Medical  Eecord,"  October,  1877. 


i 


VENTRAL    HERNIA— DIAPHRAGMATIC   HERNIA.  573 

and  the  sac  divided  sufficiently  to  allow  the  introduction  of  the  finger. 
upon  wliich  the  further  division  of  the  sac  is  made.  If  the  finger-nail 
can  now  be  insinuated  between  the  neck  of  the  hernia  and  the  constrict- 
ing ring,  it  should  be  done,  holding  the  palmar  aspect  of  the  finger 
toward  the  pubes.  The  probe-pointed  bistoury  is  now  introduced  fiat- 
wise,  and  the  constriction  divided  for  not  more  than  a  quarter  of  an  inch 
at  first.  The  dii'ection  of  this  cut  should  be  in  the  median  line,  and 
toward  the  pubes  ;  or  the  constriction  may  be  incised  on  the  iipper  asj)ect 
of  the  neck  if  more  convenient  to  the  operator. 

The  management  of  the  strangulated  bowel  or  omentum  should  be 
the  same  as  advised  in  inguinal  hernia.  The  sac  should  be  transfixed 
with  a  strong  double  catgut  ligature,  tied  each  way,  the  part  beyond  the 
ligatures  cut  'off,  and  the  stump  returned  within  the  abdomen.  The 
radical  cure  should  be  attemjited  by  introducing  a  flat  Thiersch  sponge 
through  the  opening,  which  %\ill  prevent  blood  or  other  matter  from  en- 
tering the  peritoneal  cavity.  The  margins  of  the  opening  should  now 
be  trimmed  so  as  to  secure  freshened  edges  for  approximation.  When 
all  bleeding  has  ceased,  the  sjjonge  should  be  removed,  and  the  fascia, 
aponeuroses  of  the  muscles,  and  integument  brought  together  by  silk 
sutures,  as  above  directed. 

Ventral  Tiernia.  is  amenable  to  the  same  general  treatment  as  the 
acquired  umbilical  variety.  In  operation  for  the  cure  of  hernia  after 
laparotomy,  the  parietal  peritonaeum  should  be  first  closed  with  catgut. 
In  closing  the  remainder  of  the  wound  the  sutures  should  be  made  to 
include  both  layers  of  the  dense  sheath  of  the  rectus  muscle. 

In  one  of  the  author's  cases  the  recti  muscles,  during  violent  straiuing 
at  parturition,  were  split  apart  from  a  point  three  inches  below  the 
xiphoid  appendix  to  within  an  equal  distance  of  the  pubes.  At  least 
two  thirds  of  the  small  intestines  and  a  portion  of  the  transverse  colon 
were  prolapsed  into  this  enormous  hernia.  After  incision  over  the  entire 
extent  of  the  tumor,  the  intestines  were  reduced,  a  strip  of  skin  varying 
in  width  from  one  half  to  two  inches  was  trimmed  off  from  each  side  on 
account  of  redundancy,  and  the  wound  closed  by  large  silk  sutures,  which 
ti-ansfixed  the  entire  thickness  of  the  abdominal  wall  of  each  side.  A 
cure  was  effected. 

In  diapJiragmatic  hernia  the  diagnosis  must  be  based  upon  the  symp- 
toms of  obstruction.  Pleuritis  will  be  present  in  a  varying  degree.  The 
only  means  of  amving  at  a  positive  diagnosis  is  to  make  the  median 
incision,  with  manual  exploration.  The  hernia  may  be  reduced  by  trac- 
tion, with  or  without  dilatation  of  the  opening  in  the  diaiahragm.  The 
prognosis  is  unfavorable,  and  the  gravity  is  increased  as  operative  inter- 
ference is  delayed. 

The  recognition  of  gluteal  Tiernia  is  also  difficult.  If  with  the  symp- 
toms of  obstruction  there  is  pain  in  the  region  of  tlie  sciatic  notch,  or  in 
the  distribution  of  the  gluteal  or  sciatic  nei'ves,  which  is  increased  by 
direct  pressure,  the  presence  of  gluteal  hernia  is  usually  certain.  If  a 
tumor  is  appreciable,  it  is  still  more  positive. 

To  locate  the  notch,  place  the  patient  on  his  belly  and  hold  the  leg 


574  A  TEXT-BOOK   ON   SURGERY. 

perfectly  straight,  with  the  toes  pointing  directly  downward.  A  line, 
drawn  from  the  posterior  superior  spine  of  the  ilium  to  the  njjper  sur- 
face of  the  great  trochanter,  will  cross  over  the  foramen. 

The  incision  should  be  free,  and  the  fibers  of  the  gluteal  muscles 
separated  with  the  finger.  The  vessels  should  be  located  before  the  con- 
striction is  divided. 

Obturator  hernia  may  be  present  without  any  appreciable  tumor.  It 
may  be  recognized  by  digital  exploration  through  the  rectum  or  vagina. 
Pressure  upon  the  obturator  nerve  may  produce  pain  in  the  hip  or  knee. 
If  the  symptoms  of  obstruction  are  present,  the  hand  should  be  intro- 
duced through  an  incision  in  the  linea  alba,  when,  by  careful  explora- 
tion of  the  pelvis,  the  character  of  the  lesion  can  be  determined.  In 
the  effort  at  reduction  by  traction  from  within,  the  thigh  should  be  ro- 
tated outward  to  relax  the  obturator  muscle.  If  necessary,  an  incision 
may  be  made  immediately  over  the  foramen,  and  the  constriction  divided 
from  below.  The  point  at  which  the  intestine  usually  escapes  is  in  the 
adult  between  two  and  two  and  a  half  inches  external  to  the  symphysis 
pubis,  and  on  a  line  with  the  inner  border  of  the  femoral  or  iliac  vein. 
When  the  fibers  of  the  pectineus  muscle  are  divided,  the  tumor  will  be 
encountered. 

Lumbar  and  vaginal  hernia  do  not  demand  especial  consideration. 
The  diagnosis  will  depend  upon  the  appearance  of  the  tumor,  with  the 
symptoms  of  strangulation,  when  the  constriction  is  sufficient.  The 
return  of  the  mass  which  follows  prolapsus  of  the  uterus  into  the  vagina 
may  be  effected  by  direct  reposition  of  the  uterus,  or  by  conjoined 
manipulation  with  one  hand  introduced  through  an  opening  in  the  linea 
alba. 

Fecal  Fistula. — A  fecal  fistula  may  exist  between  any  portion  of  the 
intestinal  canal  and  the  exterior  through  the  integument ;  from  the  in- 
testine into  a  normal  cavity,  as  the  bladder  or  uterus,  and  thence  to  the 
exterior  ;  into  an  abnormal  cavity,  as  an  abscess,  and  thence  out  through 
one  of  the  hollow  organs  or  directly  to  the  skin ;  or  it  may  lead  into  a 
cul-de-sac  or  blind  pocket. 

Fecal  fistulse  are  congenital  and  acquired. 

Imperforate  anus  is  the  most  frequent  cause  of  congenital  fistula. 
The  j)ressure  of  accumulated  matter  at  the  extremity  of  the  canal  in- 
duces inflammation,  ulceration,  and  perforation,  with  extravasation  of 
the  bowel  contents.  If  the  congenital  obstruction  is  low  down,  the 
opening  may  occur  through  the  perinseum,  bladder,  or  vagina.  If  high- 
er up,  the  fistula  may  open  through  the  abdominal  wall  at  the  umbili- 
cus, or  below  this  point  in  the  linea  alba,  or  posteriorly  near  the  spine. 
A  rare  cause  of  congenital  fistula  is  the  presence  of  the  omphalo-mesen- 
teric  duct,  or  Meckel's  diverticulum,  which,  as  heretofore  stated,  opens 
at  the  umbilicus. 

Acquired  fecal  fistula  may  be  surgical  or  accidental.  Colostomy 
and  enterostomy  are  examples  of  the  former,  while  the  latter  result  from 
perforating  wounds  of  the  intestinal  canal,  either  from  the  exterior,  as 
by  gun-sTiot  or  punctured  wounds^  or  by  the  passage  of  some  ingested 


FECAL  FISTULA.  575 

sharp  or  hard  body  througli  the  intestinal  wall ;  or  by  perforation  of  the 
Intestine  by  an  nicer  or  abscess,  or  from  gangrene  dne  to  strangulation, 
contusions,  etc. 

The  diagnosis  of  a  fecal  fistula  which  communicates  directly  with 
the  exterior  is  made  evident  by  the  escape  of  gas  and  ingested  matter. 
Indirect  fistulee  can  also  be  determined  by  the  careful  examination  of 
the  discharges  from  the  organs  through  which  they  pass.  In  a  case  re- 
ported by  Dr.  Krackowitzer,  iu  the  "Transactions  of  the  New  York 
Pathological  Society,"  an  ulcer  of  the  appendix  vermiformis  had  opened 
into  the  bladder.  The  diagnosis  of  entero-vesical  fistula  was  established 
by  the  escape  of  a  lumbricoid  worm  from  the  urethra.  Blind  fistulae  can 
not  often  be  made  out  until  demonstrated  by  exploration. 

In  determining  what  portion  of  the  intestinal  canal  the  fistula  opens 
into  one  must  consider,  first,  the  character  of  the  discharge  ;  second,  the 
distance  from  the  rectum,  as  determined  by  injections. 

In  congenital  fistulcB  opening  into  the  perinseum  the  inference  is 
natural  and  generally  correct  that  the  lower  portion  of  the  large  intestine 
is  involved.  If  bile  is  freely  discharged  through  a  congenital  or  ac- 
quired fistula,  it  is  safe  to  conclude  that  the  opening  is  not  very  far 
removed  from  the  duodenum  or  upper  portion  of  the  jejunum.  The 
odor  of  gas  or  ingesta  escaping  from  the  large  intestine  is  usually  more 
offensive  than  that  from  the  small  bowel. 

When  caused  by  a  wound,  the  known  direction  and  character  of  the 
penetrating  body  will  aid  in  arriving  at  a  correct  idea  of  the  gut  pene- 
trated. 

A  fistula  resulting  from  perityphUtic  abscess  occurs  almost  always 
in  the  coecum,  more  rarely  in  the  lower  portion  of  the  ascending  colon 
or  lower  ileum.  When  the  colon  is  involved  the  location  may  be  deter- 
mined by  slowly  injecting  milk  per  rectum,  having  measured  the  quan- 
tity injected  until  it  begins  to  flow  out  at  the  external  opening. 

The  prognosis  of  fecal  fistula  dejoends  upon  its  character.  Congeni- 
tal fistulee  are  obstinate  irnder  treatment.  Acquired  fistulse  may  be  cured 
in  the  majority  of  instances. 

Treatment. — Congenital  fistulse,  resulting  from  imperforate  anus,  can 
only  be  healed  by  the  establishment  of  an  opening  in  the  perinfeum 
which  shall  communicate  with  the  most  dependent  portion  of  the  blind 
gut.  When  this  is  done,  a  pad  worn  over  the  fistulous  opening  will 
lead  to  its  gradual  occlusion.  When  the  fistula  is  the  result  of  a  patti- 
lous  omiDhalo-mesenteric  canal,  it  may  be  closed  by  sutures  or  by  a  com- 
press. 

Acquired  fistulse  not  infrequently  heal  spontaneously.  The  opera- 
tion consists  in  cutting  down  upon  the  opening  in  the  gut  and  lay- 
ing freely  open  all  sinuses  which  communicate  with  the  fistulous 
outlet.  As  the  track  of  the  fistula  is  often  tortuous,  it  is  at  times  ex- 
ceedingly diflicult  to  follow  it.  A  repetition  of  the  method  employed 
in  the  following  case  will  be  of  service  in  the  more  complicated  oper- 
ations : 

In  1880  a  young  man  came  under  my  observation  on  account  of  a 


576  A  TEXT-BOOK   ON   SURGERY. 

pistol-shot  wound.  The  ball  had  entered  the  abdomen  on  a  level  with 
and  about  one  and  a  half  inch  to  the  inner  side  of  the  left  anterior  su- 
perior spine  of  the  ilium.  From  the  direction  in  which  the  weapon  was 
aimed,  the  missile  was  thought  to  have  passed  directly  back  and  lodged 
in  the  iliac  fossa.  There  were  no  immediate  symptoms  of  perfoi'ation 
of  the  intestine.  An  abscess  formed  which  discharged  from  the  wound 
of  entrance,  and,  about  six  weeks  after  the  receipt  of  the  injury,  a  fecal 
fistula  was  established.  The  fistulous  track  was  so  long  and  tortuous 
that  it  could  not  be  followed.  After  the  aneesthesia  was  complete,  warm 
milk  was  thrown  into  the  bowel  until  it  ran  out  at  the  opening.  The 
stream  of  milk  was  then  followed  without  difficulty,  and  the  opening 
discovered.  All  communicating  siniises  were  laid  open  and  packed  with 
carbolized  gauze.  The  wound  closed  within  a  month,  and  the  patient 
was  cured. 

It  will  be  advisable,  in  attempting  to  close  the  fistula,  for  the  patient 
to  maintain  a  position  which  will  prevent  the  gravitation  of  ingested 
matter  into  the  opening. 

Closure  of  the  external  orifice  by  means  of  sutures  is  not  advisable, 
since  it  may  induce  fecal  infiltration.  A  recovery  is  usually  hastened 
when  the  margins  of  the  wound  in  the  integument  can  be  stitched  to  the 
edges  of  the  opening  into  the  bowel,  as  directed  in  enterostomy. 

Colostomy. — The  establishment  of  a  fecal  fistula  between  the  colon 
and  the  abdominal  wall  is  usually  performed  in  the  coeciim  or  first 
few  inches  of  the  ascending  portion,  the  lower  part  of  the  descend- 
ing colon,  or  in  the  sigmoid  flexure. 

Colostomy  is  indicated  as  a  palliative  measure  in  occlusion  of  the 
alimentary  canal  on  the  anal  side  of  the  operation  by  stricture,  neo- 
plasms, volvulus,  intussusception,  or  any  lesion  for  the  relief  of  which 
exsectlon  or  lateral  anastomosis  is  not  permissible.  In  chronic  colitis  or 
proctitis  it  is  a  curative  operation,  in  giving  complete  rest  to  the  dis- 
eased bowel  until  recovery  ensues. 

In  selecting  the  place  of  operation,  the  right  or  left  lumbar  or  the  left 
inguinal  region  may  be  chosen,  the  aim  of  the  surgeon  being  to  get  as 
near  the  point  of  occlusion  as  possible. 

When  the  rectum  alone  is  involved,  the  left  inguinal  region  should  be 
chosen  (Littre),  for  the  sigmoid  flexure,  the  left  lumbar  region  should  be 
selected ;  if  the  descending  or  transverse  colon  are  involved,  the  right 
lumbar  incision  is  preferable. 

Callisen^s  Operation — Left  Lumibar  Colostomy. — Place  the  patient 
on  the  right  side,  inclined  well  over  upon  the  abdomen.  The  objective 
point  is  the  posterior  surface  of  the  descending  colon,  at  a  point  situated 
half-way  between  the  crest  of  the  ilium  and  the  last  rib,  and  half-way 
between  the  siDinous  process  of  the  third  lumbar  vertebra  and  the  ante- 
rior superior  spine  of  the  ilium.  Make  an  incision  about  five  inches  in 
length,  the  center  of  which  shall  strike  this  point,  commencing  about 
one  inch  from  the  vertebral  spines.  The  direction  of  this  incision  should, 
be  obliquely  from  above  downward  and  forward — that  is,  parallel  with 
the  lumbar  vessels  and  nerves.     Dividing  the  skin  and  fascia,  the  poste- 


COLOSTOMY.  577 

rior  border  of  the  abdominal  muscles  and  the  anterior  border  of  the 
quadratus  himborum  muscle  will  be  seen.  The  posterior  wall  of  the 
colon — that  portion  which  is  not  included  in  the  peritouseum — will  be 
found  a  little  posterior  to  the  border  of  this  muscle.  A  safe  guide  is  to 
insert  the  finger  along  the  edge  of  the  quadratus  muscle  and  feel  for  the 
kidney.  The  gut  is  immediately  in  front  of  this  organ.  It  is  imiDortant 
to  keep  well  toward  the  spine  in  order  to  avoid  opening  into  the  perito- 
nseum.  Usually  at  this  juncture,  with  the  wound  ]Derfectly  dry,  the  wall 
of  the  intestine  can  be  picked  up  with  the  finger  and  lifted  toward  and 
into  the  wound.  If  it  has  receded,  deep  pressure  upon  the  anterior 
wall  of  the  abdomen  will  bring  it  into  view.  If  the  cavity  of  the  peri- 
tonaeum is  not  opened,  it  is  scarcely  possible  to  get  hold  of  the  small 
intestine.  The  colon  may  be  recognized  by  its  large  size  and  by  its  sac- 
culated wall.  If  there  is  any  doubt  as  to  the  large  intestine  being  the 
one  which  presents,  the  expedient  of  pumping  air  into  the  rectum  may 
be  resorted  to,  the  immediate  distention  of  the  colon  proving  its  close 
relation  to  the  rectum.  As  soon  as  the  bowel  is  brought  into  the  wound, 
it  should  be  transfixed  by  two  strong  silk  sutures,  introduced  about  an 
inch  apart,  through  the  integument  of  one  side  into  the  intestine  for 
about  one  half  an  inch  and  out  again  and  up  through  the  margin  of  the 
incision  in  the  integument  on  the  opposite  side.  The  colon  is  now  held 
well  up  into  the  wound  by  traction  on  the  sutures  in  the  hands  of  an 
assistant,  while  the  operator  makes  a  longitudinal  incision  in  the  wall 
of  the  gut  superficial  to  the  threads  which  have  transfixed  it.  When 
this  is  done,  the  center  of  the  ligatures  is  drawn  out  by  a  tenaculum, 
divided,  and  the  four  threads  tied  securely.  From  two  to  four  addi- 
tional sutures  may  be  introduced  on  each  side,  to  guard  against  the 
infiltration  of  fecal  matter.  The  wound  in  the  integument  should  now 
be  closed  from  each  end  down  to  or  very  near  the  level  of  the  opening 
in  the  colon. 

If  there  is  much  escape  of  fecal  matter  immediately  following  the 
operation,  a  dressing  need  not  be  applied.  The  patient  should  be  made 
to  lie  upon  the  back,  in  which  position  gravity  favors  the  escape  of 
the  bowel  contents.  At  times  it  is  convenient  to  apply  an  iodoform- 
ized  and  sublimate  gauze  dressing,  with  a  bandage  around  the  abdomen. 
In  from  three  to  seven  days  the  stitches  can  be  removed,  and,  after  the 
wound  is  healed,  a  compress  and  belt  should  be  worn  to  i^revent  the 
escape  of  faeces  until  the  convenience  of  the  patient  is  suited. 

If  in  the  search  for  the  colon  the  cavity  of  the  peritonceum  is  opened, 
it  should  be  immediately  sewed  up  with  continuous  catgut  sutures. 

If,  after  colostomy,  prolapse  of  the  intestine  occurs,  it  may  be  re- 
turned and  held  in  place  by  a  properly  adjusted  compress  of  gauze.  If 
the  opening  contracts  to  such  an  extent  that  the  escape  of  fecal  matter 
is  hindered,  it  should  be  dilated  with  the  finger  or  by  means  of  a  gum 
or  sponge  tent. 

Amussat's  operation,  or  right  lumbar  colostomy,  is  performed  in  the 
same  manner  as  the  procedure  just  given,  upon  the  opposite  side  of  the 
body.     Littre's  operation  is  performed  by  opening  into  the  peritoneal 

37 


578  A  TEXT-BOOK   ON  SUKGERY. 

cavity  by  an  incision  in  the  abdominal  wall  just  internal  to  the  left  ante- 
rior spine  of  the  ilium  over  the  sigmoid  flexure.  The  small  intestines  are 
displaced  to  the  right,  while  the  sigmoid  flexure  is  brought  up  to  the 
wound  and  fastened  by  two  rows  of  sutures.  The  first,  of  fine  silk, 
attach  the  edge  of  the  parietal  peritonaeum  to  the  peritoneal  layer  of 
the  gnt,  while  those  of  the  second  row  pass  through  the  integument 
and  into  the  lumen  of  the  intestine,  as  in  colostomy.  A  like  operation 
may  be  done  upon  the  transverse  colon,  though  not  often  indicated. 

Peritonitis. — In  properly  selected  cases,  abdominal  section  for  the 
relief  of  peritonitis  with  effusion  has,  within  late  years,  become  a  recog- 
nized operation.  It  is  more  applicable  to  cases  of  local  peritonitis,  and 
in  chronic  inflammation  of  this  membrane,  than  in  acute  general  perito- 
nitis. The  operation  is  justifiable  in  the  acute  inflammation  which  fol- 
lows perforation  of  the  alimentary  canal,  in  which  closure  of  the  perfo- 
ration, and  a  thorough  cleansing  of  the  cavity  of  the  j)eritonseum,  are 
essential.  Left  without  operation,  these  cases,  almost  without  exception, 
end  fatally  ;  also  in  chronic  local  peritonitis,  due  to  any  cause  in  which 
the  symptoms  of  septic  absorption  are  prominent.  The  same  principle 
should  apply  in  these  cases  as  in  chronic  effusions  into  the  pleural  cavity.* 
Mr.  Treves,  in  his  excellent  monograph,  cites  a  series  of  cases :  one  in 
which  Mr.  Hancock  opened  the  abdomen  for  chronic  local  peritonitis, 
due  to  disease  of  the  vermiform  appendix  ;  Mr.  Tait,  in  several  cases  of 
chronic  peritonitis  ;  Dr.  Savage,  in  eight  cases  of  pelvic  jDeritonitis  treated 
by  laparotomy ;  Dr.  Playfair,  in  one  case  of  chronic  puerperal  perito- 
nitis— all  ending  in  recovery,  f  When  the  incision  is  made,  any  effused 
liquid  or  pus  should  be  removed  by  means  of  soft  Thiersch  sponges  on 
holders,  and  the  cavity  of  the  peritonaeum  flooded  with  warm  Thiersch 
solution  or  1  to-20000  sublimate  solution,  or,  if  neither  of  these  can  be 
had,  with  clean  warm  water  at  a  temperature  of  100°  to  110°  F.  As 
soon  as  it  is  introduced  it  should  be  removed  with  the  sponges,  and 
-the  irrigation  repeated  until  it  comes  away  clear. 

In  several  instances  I  have  seen  the  sublimate  solution  emploj'-ed  in 
this  manner  in  disinfection  of  the  entire  peritoneal  cavity  with  success. 

In  severe  and  obstinate  cases,  drainage  should  be  established  in  the 
same  manner  as  described  in  the  after-treatment  of  certain  ovarian  tumors. 

In  the  diagnosis  of  peritonitis,  pain,  though  not  always  present,  is  in 
the  majority  of  instances  an  early  and  prominent  symptom.  It  is  intense 
in  character,  almost  constant,  being  first  noticed  in  a  given  j)oint  and 
extending  later  with  the  progress  of  the  inflammation  to  any  portion 
of  the  abdominal  cavity.  Tympanites  exists  in  a  varying  degree,  the 
patient  generally  lying  upon  the  back,  with  the  legs  drawn  up  and  the 
thighs  flexed  upon  the  abdomen.  The  abdominal  muscles  are  usually 
rigid,  taking  no  part  in  the  respiratory  act.  Constijjation  is  the  rule  in 
a  large  majority  of  cases.  Yomiting  is  not  so  common  a  feature,  though 
often  occurring  in  peritonitis.  Difficulty  in  urinating,  or  complete  reten- 
tion, occurs  in  some  cases,  especially  in  those  in  which  the  inflammatory 

*  "Intestinal  Obstruction."     Lea,  Sons  &  Co.,  Pliiladelpliia,  1884.  t  Ibid. 


ABSCESS  IX  THE  ABDOMINAL  REGIOX.  579 

process  is  marked  in  tlie  pelvic  region.  The  pnlse  is  increased  in  fre- 
quency. Peritonitis  is  in  almost  all  instances  secondary  to  a  lesion  of 
one  or  more  of  the  abdominal  viscera. 

Abscess  in  tJie  Abdominal  Region. — Abscess  may  occur  between  the 
parietal  layer  of  the  peritonfeum  and  the  muscular  walls  of  the  abdo- 
men, within  any  circumscribed  area  of  the  peritoneal  cavity,  in  the  loose 
tissues  behind  the  peritonseum  (retro-peritoneal  abscess),  and  in  the  sub- 
stance or  ^^•ithin  the  capsules  of  any  of  the  viscera. 

The  diagnosis  of  extra-peritoneal  abscess  will  in  part  depend  upon 
the  localised  pain  or  tenderness  under  pressure,  and  the  induration  and 
oedema  which  are  characteristic  of  acute  inflammation  with  pus-forma- 
tion, together  with  the  usual  exacerbations  of  temperature,  with  or  ^nth- 
out  rigors  or  a  chill.  Fluctuation  may  be  appreciable  in  exti-a-peritoneal 
abscess  in  patients  with  thin  abdominal  walls,  and,  if  situated  between 
the  muscles  or  in  the  subcutaneous  tissues,  is  usually  diagnosticated 
without  ditBculty.  The  employment  of  the  exploring-needle  and  aspi- 
rator is  always  invaluable  in  the  recognition  of  an  abscess.  The  imme- 
diate indication  in  treatment  is  to  cut  down  upon  the  tumor,  using  the 
needle  which  has  indicated  the  presence  of  pus  as  a  guide,  until  the  sac 
is  reached,  puncturing  this  sufiiciently  to  admit  the  point  of  the  closed 
dressing-forceps,  and  enlarging  the  opening  by  separating  the  handles 
of  the  instrument.  The  principles  of  irrigation  and  free  drainage  apply 
here  as  to  other  recent  collections  of  pus. 

Intra-peritoneal  abscess  is  usually  single,  although  in  exceptional 
instances  there  may  be  two  or  more  different  centers  of  suppuration. 
The  most  frequent  locations  are  the  iliac  regions  and  the  pelvis.  In- 
flammation of  the  ccecum  and  vermiform  appendix,  and  the  peritoneeum 
immediately  about  these  organs  {typhlitis  and  peritypJilitis),  is  a  not 
infrequent  cause  of  abscess.  All  of  tlie  lesions  considered  under  the 
head  of  intestinal  obstruction  may  induce  the  formation  of  pus  in  the 
cavity  of  the  peritonseum.  Abscess  occasionally  forms  between  the 
upper  surface  of  the  Kver  and  spleen  and  the  diaphragm  as  a  result  of 
tearing  loose  portions  of  the  suspensory  ligaments  of  these  organs. 

Dio.gnosis. — Intra-peritoneal  abscess  must  be  differentiated  fi'om  neo- 
plasms, cysts,  fecal  impaction,  with  coecitis  or  colitis,  all  tumors  result- 
ing from  obstruction,  hydronephrosis,  aneurism,  hfematoma,  and  abscess 
within  the  solid  viscera.  The  characteristic  features  of  neoplasms,  fecal 
impaction,  and  the  various  lesions  which  induce  intestinal  occlusion,  have 
just  been  considered.  Hydronephrosis  develojis  slowly,  and  has  a  his- 
tory of  obstruction  of  the  ureter  or  urethra  which  can  not  be  mistaken, 
while  the  expansile  pulsation  and  bruit  of  an  aneurism  render  it  easy 
of  recognition.  Abscess  develops  quickly,  and  follows  an  injury  or  oc- 
curs in  the  course  of  some  inflammatory  process.  If,  after  a  blow  in  the 
hypochondriac  region,  or  a  severe  fall,  tenderness  is  developed  along 
the  upper  surface  of  the  liver  or  spleen,  accompanied  by  the  well-known 
constitutional  symptoms  of  pus-formation,  perihepatic  or  perisplenic  ab- 
scess may  be  suspected.  The  same  symptoms,  occurring  in  the  course 
of  typhlitis  or  perityphlitis,  point  to  suppuration  ia  the  region  of  the 


580  A  TEXT-BOOK   ON   SURGERY. 

coecum.  In  like  manner  ovaritis,  metritis,  salpingitis,  cystitis,  and  pelvic 
cellulitis  are  conditions  which  not  infrequently  induce  abscess  in  the 
pelvic  jDeritonpeum. 

Induration  and  fluctuation  are  scarcely  appreciable  in  the  earlier  stages 
of  abscess  between  the  liver  or  spleen  and  diaphragm  on  account  of  the 
resistance  offered  by  the  ribs.  Localized  pleuritis  and  pain  in  the  re- 
spiratory act  should  not  be  without  signiflcance  when  considered  with 
other  symptoms.  In  perityphlitic  abscess  induration  is  felt  early  in  the 
inflammatory  process,  tenderness  is  well  marked,  while  muscular  rigidity, 
especially  of  the  right  side  of  the  abdomen,  is  present.  There  are  dull- 
ness on  percussion  and  oedema  of  the  skin.  As  the  inflammatory  process 
extends,  the  induration  becomes  more  superficial  or  descends  along  the 
iliac  fossa.  Fluctuation  is  deep-seated  and  diflBcult  of  recognition  until 
there  is  either  pus  in  large  quantity,  or  the  wall  of  the  abscess  has  risen 
in  close  proximity  to  the  integument.  In  abscess  within  the  pelvis,  ex- 
ploi'ation  by  the  rectum  or  vagina  will  aid  in  a  correct  diagnosis. 

Treatment. — In  perihepatic  abscess  the  pus  should  be  evacuated  by 
means  of  the  aspirator.  The  needle  should  be  of  sufiicient  caliber  to 
allow  the  pus  to  come  away  freely,  and  should  be  introduced  in  the 
same  opening  and  to  the  same  depth  of  the  smaller  needle  which  was 
employed  in  arriving  at  a,  diagnosis.  Washing  out  the  cavity  of  the 
abscess,  when  it  is  .of  recent  formation,  is  not  advisable  for  fear  of  over- 
distention  and  ruptui-e  of  the  sac.  Incision  and  free  drainage  may  be 
employed  when  the  abscess  is  large,  the  pus  superficial,  and  when  ad- 
hesions have  occurred  which  will  prevent  infiltration  into  the  general 
cavity  of  the  abdomen  or  pleura. 

PeritypJiUtic  abscess  demands  operative  interference  as  soon  as  the 
symptoms  point  to  a  collection  of  pus. 

In  appendicitis  with  symptoms  of  perforation  operation  is  urgent  and 
should  be  undertaken,  unless  a  condition  of  collapse  supervenes  so  rap- 
idly as  to  contra-indicate  interference.  The  inflammatory  changes  in 
perityphlitis  are  now  understood  to  proceed  in  almost  all  cases  from 
lesions  of  the  appendix  vermiformis,  the  abscess  when  resulting  being 
primarily  intra-peritoneal.  Appendicitis  may  be  due  to  the  presence  of 
a  foreign  substance  in  this  organ,  or  idiopathic  ulcer  of  the  wall  may  lead 
to  peritonitis  and  perforation,  or  gangrene  may  occur,  possibly  from  inter- 
ference of  its  proper  blood-supply  from  pressure  by  surrounding  viscera. 

The  diagnosis  is,  as  a  rule,  attended  with  considerable  difiiculty. 
While  pain  varying  in  severity  is  usually  present,  it  may  be  absent  until 
perforation  occurs.  It  is  usually  acute  in  character,  and  by  careful  and 
direct  pressure  with  the  index-finger  alone  may  be  localized  about  two 
inches  from  the  right  anterior  iliac  spine,  on  a  line  drawn  from  this 
point  to  the  umbilicus.  Muscular  rigidity  over  the  right  iliac  region 
may  be  mistaken  for  inflammatory  induration.  High  febrile  movement 
points  to  the  formation  of  pus  rather  than  to  spreading  peritonitis.  The 
propriety  of  operation  miist  be  determined  by  a  careful  study  of  the 
individual  case,  and  in  no  surgical  disease  is  it  so  difiicult  to  give  any 
positive  rule  as  in  the  one  under  consideration. 


PERITTPHLITIC  ABSCESS.  581 

When  the  accumulation  of  pus  is  evident  from  recognizable  tumefac- 
tion, or  oedema  of  the  abdominal  wall,  incision  is  imperative.  In  cases 
of  doubt,  careful  incision  adds  little  to  the  gravity  of  the  situation  and 
is  therefore  advisable.  Exploration  with  the  aspirator  needle  is  scarcely- 
permissible,  unless  by  incision  it  is  demonstrated  that  adhesions  have 
occurred.  Then  its  use  is  indicated  in  determining  the  exact  location  of 
the  pus.  If  adhesions  do  not  exist,  the  peritoneal  cavity  may  be  opened 
and  the  condition  of  the  appendix  ascertained  by  inspection.  Great  care 
should  be  exercised  in  manipulating  the  organs  involved  for  fear  of 
breaking  down  adhesions  between  contiguous  layers  of  peritongeum  and 
thus  spreading  the  infection.  If  the  appendix  is  found  to  be  diseased,  it 
may  be  tied  off  near  the  caecum  with  a  silk  ligature  and  removed.  If 
general  peritonitis  is  threatened,  especially  if  perforation  has  occurred,  a 
most  careful  cleansing  of  the  part  in  the  field  of  operation  should  be 
done.  It  is  often  safer  not  to  close  the  wound,  but  to  cut  off  the  danger 
of  infection  by  surrounding  the  location  of  the  appendix  with  a  firm 
wall  (packing)  of  iodoformized  gauze,  removing  this  in  a  few  days  after 
firm  adhesions  have  been  established.  When  abscess  is  present,  it  should 
be  evacuated  and  drained.  The  incision  in  all  cases  should  be  perpen- 
dicular and  directly  over  the  known  location  of  the  caecum  and  appendix. 
Fecal  fistula  forming  in  the  course  of  appendicitis  or  perityphlitis 
should  be  treated  as  advised  for  other  forms  of  fecal  fistulae. 

Retroperitoneal  Abscess. — Abscess  behind  the  peritonaeum  is  usually 
circumscribed,  although  it  may  be  diifuse.  Commencing  at  any  portion 
of  the  posterior  abdominal  wall,  pus  is  apt  to  dissect  up  the  loose  tissues 
behind  the  peritonaeum,  and  to  travel  downward,  pointing  ultimately  in 
one  of  the  following  situations :  Above  Poupart's  ligament,  external  to 
its  center ;  beneath  this  ligament,  in  Scarpa's  space  ;  over  the  iliac 
crest ;  in  the  gluteal  or  lumbar  region ;  at  the  obturator  foramen,  or 
less  frequently  it  may  empty  into  the  colon,  rectum,  bladder,  uterus, 
vagina,  or  pass  out  through  the  perineeum.  Occasionally  the  dissec- 
tion is  upward  into  the  pleura,  or  it  may  pass  across  the  spine  to  the 
opposite  side. 

Causes. — Ostitis  of  the  vertebrae,  ribs,  or  bones  of  the  pelvis,  rupture 
of  the  psoas  or  iliacus  muscles ;  lesions  of  the  kidneys  or  supra-renal 
capsules  (cysts,  neoplasms,  calculi,  pyelitis,  rupture  with  the  extravasa- 
tion of  blood  and  urine) ;  diseases  of  the  pancreas,  liver,  spleen,  duo- 
denum, colon,  and  rectum  ;  the  pelvic  viscera,  or  tubercular  changes  in 
the  lymphatics  of  this  region — may  cause  retroperitoneal  abscess. 

Diagnosis. — The  physical  signs  of  the  earlier  stages  of  ]3us-forma- 
tion  behind  the  peritonaeum  are  not  well  marked.  With  the  muscles 
fully  relaxed,  deep  pressure  upon  the  abdomen  from  before  backward 
may  demonstrate  the  presence  of  the  swelling.  Rigidity  of  the  muscles 
of  the  affected  side  is  apt  to  be  present,  and  in  walking  there  is  usually 
a  perceptible  limp.  When  the  inflammatory  process  is  situated  in  the 
region  of  the  iliacus  and  psoas  muscles,  flexion  of  the  thigh  on  the  ab- 
domen, hov/ever  slight,  is  apt  to  occur.  The  constitutional  symptoms 
of  acute  abscess  will  be  the  chief  reliance  in  arriving  at  a  correct  diag- 


582  A  TEXT-BOOK   ON   SURGERY. 

nosis.  The  history  of  an  injury,  or  the  presence  of  a  lesion  of  any  of  the 
organs  situated  in  this  region,  will  suggest  the  probability  of  abscess. 

Extravasation  of  blood  {hcBviatoma),  as  far  as  the  swelling  is  con- 
cerned, may  simulate  abscess,  and  in  one  particular  may  mislead,  since 
the  blood  dissects  up  the  loose  tissues,  and  the  tumor  may  present  at 
any  of  the  locations  named  for  the  pointing  of  the  abscess.  The  sud- 
denness of  the  tumefaction  in  haemorrhage,  the  history  of  an  injury  (or  it 
may  be  aneurism),  and  the  absence  of  septic  fever,  are  sufficient  to  ex- 
clude abscess.  Lesions  of  the  kidneys  may  be  recognized  by  a  careful 
study  of  the  urine.  In  hydronephrosis  the  swelling  will  occur  without 
marked  pain  or  fever,  comes  on  gradually,  while  a  history  of  obstruc- 
tion will  be  given.  Tenderness  along  the  spines  of  the  vertebrae  sug- 
gests abscess.  Lastly,  the  aspirator-needle  introduced  from  behind  will 
determine  the  character  of  the  swelling. 

Treatment. — Incision  and  free  drainage  should  be  the  rule  of  prac- 
tice in  acute  retroperitoneal  abscess.  When  the  pus  is  deep-seated,  opera- 
tion should  be  delayed,  provided  that  the  symptoms  of  septic  absorption 
are  not  too  urgent.  The  patient  should  be  kept  quiet  and  in  bed,  and  in 
the  dorsal  decubitus.  The  operation  and  after-treatment  are  practically 
the  same  as  in  extra-peritoneal  abscess. 


The  Liver. 

Hepatic  Abscess. — A  circumscribed  collection  of  pus  within  the  sub- 
stance of  the  liver  is  comparatively  rare.  Usually  single,  there  may  be 
two  or  more  separate  abscesses,  which  vary  in  size  from  a  few  lines  in 
diameter  to  enormous  cavities  holding  a  gallon  or  more  of  pus.  They 
may  be  deep  or  superficial,  and,  while  no  portion  of  the  liver- substance 
is  exempt,  the  most  frequent  location  is  in  the  deeper  portions  of  the 
right  lobe. 

Causes. — Contusions,  lacerations,  penetrating  wounds,  and  the  lodg- 
ment of  foreign  bodies  are  among  the  traumatic  causes  of  suppurative 
inflammation  of  the  liver.  Laceration  of  the  capsule  along  the  attached 
l^ortion  of  the  suspensory  and  coronary  ligaments  not  only  leads  to  peri- 
hepatic abscess,  but  may  induce  suppuration  in  the  deeper  portions 
of  this  organ.  Foreign  bodies  causing  hepatic  abscess  not  only  enter 
through  the  integument,  but  ingested  substances,  as  bones,  needles,  etc., 
have  been  known  to  pass  from  the  alimentary  canal  into  the  liver,  pro- 
ducing circumscribed  inflammation  and  suppuration.  Abscess  of  the 
liver  may  also  occur  secondary  to  an  inflammatory  process  in  any  of  the 
abdominal  organs  the  blood  from  which  is  returned  by  the  portal  vein. 
Lastly,  it  may  occur  in  the  course  of  acute  hepatitis,  where  neither  in- 
jury or  metastasis  has  occurred.  As  this  disease  is  almost  altogether 
confined  to  tropical  climates,  it  will  be  understood  why  hepatic  abscess 
is  so  much  more  frequent  there  than  in  the  colder  zones. 

Symptoms  and  Diagnosis. — The  early  recognition  of  hepatic  abscess 
is  exceedingly  difficult,  especially  when  the  deeper  portions  of  the  organ 


ABSCESS  OF  THE  LIVER.  583 

are  involved.  Pain  is  not  a  prominent  symptom,  unless  there  exists  a 
perihepatitis,  in  which  case  it  is  exaggerated.  There  is  a  sense  of  heavi- 
ness or  fullness  about  the  liver,  exacerbations  of  temperature  occur, 
with  general  impairment  of  health.  Jaundice  is  not  present  unless  the 
bUe-duct  is  compressed  by  the  tumor.  Cancer  of  the  liver  develops 
slowly,  has  a  history  of  progressive  emaciation,  occurs  usually  after  forty 
years  of  age,  and  is  nodular  to  the  feel. 

Empyema  may  be  mistaken  for  abscess  of  the  liver,  especially  when 
the  accumulation  is  considerable  and  the  Uver  is  displaced  downward. 
It  may  be  recognized  by  the  interference  with  the  expansion  of  the  lung 
of  the  affected  side,  and  by  the  change  in  the  percussion-sounds  with 
the  change  in  position  of  the  thorax,  in  which  the  fluid  of  emjjyema  is 
displaced. 

Over- distended  gall-bladder  may  be  mistaken  for  abscess;  but  this 
error  may  be  eliminated  by  bearing  in  mind  its  location  in  front  and 
low  down,  where  abscess  is  exceedingly  rare,  and  also  by  observing 
that  a  distended  gall-bladder  is  appreciably  movable  independently  of 
the  liver. 

Hydatid  cyst  of  the  liver  is  not  paiuf  ul,  and  is  not  accompanied  with 
exacerbations  of  temperature,  with  the  exception  of  the  very  rare  occur- 
rence of  inflammation  of  the  cyst,  when  a  differentiation  is  practically 
impossible  without  aspiration  and  the  examination  of  the  fluid. 

When  the  accumulation  of  pus  is  considerable,  the  tumefaction  may 
be  recognized  by  palpation  and  the  diagnosis  made  positive  by  the  ex- 
ploring-needle. 

The  prognosis  is  iinfavorable.  Left  alone,  a  fatal  termination  occurs 
in  almost  aU  cases — by  rupture  into  the  peritonseum  in  about  30  per  cent, 
into  the  lung  in  25  per  cent,  while  in  a  smaller  proportion  of  cases  the 
abscess  opens  through  the  integument. 

Treatment. — Evacuation  is  the  only  rational  treatment.  In  the  choice 
of  methods  the  character  of  the  abscess  will  determine  the  emj)loyment 
of  the  aspirator  or  di-ainage  by  incision. 

Aspiration  is  advisable  when  the  abscess  is  deeply  located,  and 
especially  so  when  strong  inflammatory  adhesions  have  not  been  formed 
between  the  wall  of  the  abscess  and  the  abdominal  or  thoracic  parietes. 
In  performing  this  operation  the  following  plan  should  be  ado]Dted : 

The  most  siiperficial  point  of  the  abscess  should  be  located  by  care- 
ful exploration  with  the  smallest  aspirator-needle,  and  the  thickness  of 
the  intervening  tissue  measured.  In  using  the  evacuator  it  is  necessary 
to  have  a  good- sized  needle  to  prevent  solid  particles  or  shreds  of  tissue 
from  the  abscess-wall  from  occluding  it ;  but  it  is  always  safer,  if  firm 
adhesions  have  not  occurred,  to  employ  the  smaller  points,  since,  after 
the  needle  is  withdrawn,  pus  is  not  so  apt  to  escape  and  find  its  way  into 
the  pleural  or  peritoneal  cavities. 

The  needle  should  be  introduced  in  the  same  opening  and  to  the 
same  depth  as  the  exploring-needle,  and  the  pus  slowly  withdrawn.  It 
is  considered  a  safer  plan  not  to  completely  empty  the  cavity  at  the  first 
operation.     The  procedure  should  be  repeated  on  the  second  or  third 


584  A  TEXT-BOOK  ON  SURGERY. 

day.  A  piece  of  sublimate  gauze  should  be  laid  over  the  puncture  and 
held  in  position  by  a  roller.  When,  after  repeated  use  of  the  aspirator, 
a  cure  is  not  eifected,  and  when  the  tissues  between  the  most  superficial 
portion  of  the  abscess  and  the  integument  have  been  so  solidified  by 
adhesions  that  infiltration  of  pus  can  not  occur,  the  abscess  should  be 
opened  by  direct  incision,  its  contents  allowed  to  escape,  the  sac  thor- 
oughly irrigated  with  l-to-5000  sublimate,  and  a  drainage-tube  inserted. 
If,  after  cutting  down  to  the  wall  of  the  abscess,  it  is  discovered  that 
adhesions  have  not  occurred,  the  sac  should  not  be  opened.  The  wound 
should  be  packed,  v/ith  sublimate  gauze,  and,  in  four  or  five  days  after 
adhesions  have  been  established,  it  may  be  incised. 

Gall-Bladder. 

Cystotomy  of  the  gall-bladder  {cTiolocystotomy)  may  be  indicated  in 
obstruction  of  the  cystic  or  common  duct  from  any  cause,  and  in  the 
accumulation  of  concretions  (gall-stones)  in  this  organ.  The  symptoms 
are  pain  in  the  known  location  of  the  gall-bladder,  at  times  tumefaction 
due  to  its  distention,  and  in  a  proportion  of  cases  symptoms  referable  to 
the  retention  and  absorption  of  bile.  The  operation  consists  in  cutting 
down  upon  the  bladder  and  securing  adhesions  to  the  opening  by  suture, 
and  then  either  immediately,  or  preferably  in  twenty-four  to  forty-eight 
hours  after  secure"  adhesions  have  taken  place,  opening  the  sac  and 
removal  of  the  ofl'ending  substances.  The  fistula  thus  established  is 
obliterated  by  granulation,  or,  as  has  been  done,  extirpation  may  be  per- 
formed. 

Hydatid  Tumors. — Cystic  tumors  caused  by  the  presence  of  the  echi- 
nococcus  hominis,  the  larva  of  the  tsenia  echinococcus  or  tape-worm, 
occur  in  the  liver  more  frequently  than  in  all  other  portions  of  the  body. 
They  vary  in  size,  may  be  multiple  or  single,  and  may  be  lodged  in 
any  portion  of  the  organ.  The  capsule  or  periphery  of  the  cyst  is  firm 
and  dense,  and  may  undergo  calcification.  Developing  in  the  liver, 
hydatid  cysts  may  perforate  the  diai)hragm,  rupture,  and  pour  their 
contents  into  the  pleura  or  lung  ;  or  they  may  extend  into  the  abdomi- 
nal cavity  as  far  down  as  the  pelvis.  In  rare  instances  they  open  into 
the  stomach,  vena  cava,  duodenum,  or  colon. 

The  diagnosis  of  hydatids  of  the  liver  may  be  made  from  abscess  by 
recognizing  an  elastic  fluctuating  tumor,  which  is  free  from  tenderness  or 
any  of  the  symptoms  of  inflammation  or  septicsemia  which  are  always 
present  in  abscess ;  from  cancer  of  the  liver  by  its  fluctuation,  cancer 
being  solid,  hard,  and  nodulated.  The  cachexia  of  cancer  does  not  occur 
in  hydatids. 

In  distention  of  the  gallbladder  jaundice  is  apt  to  exist,  while  it  is 
an  exceptional  complication  of  hydatid  cysts.  Aspiration  with  a  deli- 
cate needle  will  be  necessary  to  positive  diagnosis.  Hydatid  cysts  con- 
tain a  watery  liquid,  nearly  clear  or  of  a  light  straw-color.  In  some  in- 
stances fragments  of  the  hooklets  and  other  contents  of  the  cysts  may  be 
discovered. 


THE   SPLEEN.  585 

Treatment. — The  contents  should  be  drawn  off  with  the  aspirator, 
and  the  operation  repeated  if  necessary.  A  single  evacuation  not  infre- 
quently effects  a  cure. 

The  needle  should  be  introduced  into  the  most  superficial  portion  of 
the  tumor.  As  the  cyst  is  being  emptied,  the  abdominal  wall  imme- 
diately around  the  needle  should  be  pressed  toward  the  tumor,  and, 
when  the  operation  is  finished,  this  should  be  continued  by  a  compress 
of  sublimate  gauze,  held  snugly  in  place  by  a  bandage.  The  object  of 
this  is  to  prevent  infiltration  of  the  Huid  into  the  peritoneal  cavity.  In 
performing  this  operation  an  anaesthetic  should  not  be  administered,  on 
account  of  the  danger  of  rupture  of  the  cyst  from  vomiting.  Cocaine 
may  be  employed  locally.  Complete  rest  in  the  recumbent  posture 
should  be  enforced  for  at  least  a  week  after  the  aspiration.  If  at  any 
time  suppuration  is  precipitated,  direct  incision  and  free  drainage  are 
imperative.  If  repeated  aspirations  fail  to  effect  a  cure,  adhesions  being 
formed  as  a  result  of  the  frequent  introduction  of  the  needle,  an  incision 
may  be  made,  or  the  operation  of  Verneuil  performed.  This  consists  in 
the  introduction  of  a  large  trocar  and  canula,  evacuating  the  contents, 
and  inserting  for  prolonged  drainage  a  large  rubber  tube  through  the 
canula,  which  is  then  withdrawn,  leaving  the  tube  in  position. 

The  Spleen. 

Abscess. — Abscess  of  this  organ  is  much  less  frequent  than  in  the  liver. 
It  may  exist  in  the  substance  of  the  spleen  or  in  the  perisplenic  tissues. 

Abscess  of  the  spleen  may  be  caitsed  by  violence,  as  from  a  pene- 
trating wound,  a  contusion  with  laceration,  or  a  more  or  less  extensive 
ruptui-e  of  the  capsule  and  spleen- substance  near  the  attachment  of  the 
suspensory  ligament. 

IcliopafhiG  abscess  of  this  organ  may  be  caused  by  embolism,  or  fol- 
low in  the  course  of  any  disease  which  interferes  with  its  nutrition. 

The  prognosis  of  splenic  abscess  is  unfavorable.  If  left  without  sur- 
gical interference,  the  contents  may  esca^De  into  the  alimentary  canal  (as 
the  colon  or  stomach) ;  into  the  pleural  cavity  and  lung  ;  or,  in  excep- 
tional instances,  open  through  the  integument.  Occasionally  abscess  of 
the  spleen  reaches  a  certain  size,  remains  passive,  and  becomes  a  chronic 
or  cold  abscess. 

Symptoms  and  Diagnosis. — Traumatic  abscess  may  be  suspected 
when,  after  an  injury,  persistent  tenderness  is  felt  in  the  region  of  this 
organ,  and  when  to  this  symptom  is  added  the  constitutional  disturbance 
which  is  a  part  of  the  history  of  acute  abscess.  In  general,  the  tender- 
ness is  more  marked  in  perisplenic  abscess  than  in  that  which  is  deep- 
seated.  Swelling,  with  induration,  possibly  fluctuation  and  oedema  when 
the  abscess  is  near  the  surface,  are  confirmatory  symptoms  of  suppura- 
tion, which  may  be  substantiated  by  the  exploring-needle  and  aspirator. 

In  idiopathic  abscess  the  symptoms  of  suppuration  may  be  masked 
by  the  febrUe  movement  in  the  disease  in  the  course  of  which  it  occurs. 
The  treatment  is  the  same  as  for  hepatic  abscess. 


586  A  TEXT-BOOK  ON  SURGERY. 

Cysts. — The  diagnosis  and  treatment  of  cysts  of  the  spleen  do  not 
differ  in  any  essential  features  from  similar  lesions  in  the  liver. 

Hernia  of  this  organ  may  occur  through  a  wound  in  the  abdomen, 
or  through  an  opening  resulting  from  extensive  sloughing.  If  the  hernia 
is  recent,  and  the  prolapsed  portion  is  not  strangulated,  it  should  be 
thoroughly  cleansed  in  l-to-5000  sublimate  solution  and  returned  into  its 
normal  position.  The  structure  of  the  spleen  is  so  delicate  that  it  breaks 
down  readily  if  nndue  force  is  employed.  If  the  organ  is  lacerated,  it 
will  be  advisable  to  throw  an  elastic  ligature  around  it  at  the  level  of  the 
skin,  apply  an  antiseptic  dressing,  and  allow  the  mass  to  be  removed  by 
sloughing  or  by  the  scissors,  as  soon  as  adhesions  have  occurred  at  the 
opening.  When  strangulation  has  taken  place,  the  ligature  will  not  be 
required. 

Complete  splenectomy  may  be  demanded  in  disj^lacement  of  this 
organ,  followed  by  interference  with  the  function  of  other  viscera,  or  for 
the  relief  of  pain  caused  by  the  spleen  in  an  abnormal  position.  It  has 
been  performed  in  several  instances  on  account  of  the  enlargement  of 
this  organ  in  leucocythsemia,  but  without  the  success  which  would  en- 
courage a  repetition  of  the  operation. 

In  the  extirpation  of  a  wandering  spleen,  the  incision  should  be  by 
preference  in  the  linea  alba,  when  the  tumor  is  near  enough  to  be  reached 
through  an  opening  here.  All  adhesions  should  be  divided  between 
double  catgut  ligatiires.  The  splenic  vessels  should  be  tied  with  a  double 
ligature  of  strong  silk,  and  divided  between  the  knots. 

Pancreas. — Cystic  tumors  of  large  size  are  occasionally  met  with  in 
this  organ,  and  have  been  successfully  removed  by  incision  in  the  median 
line,  the  operation  being  practically  the  same  as  in  ovariotomy. 


Wounds  of  the  Abdomen. 

Injuries  of  the  abdomen  are  divided  into  penetrating  and  non-pene- 
trating, and  both  of  these  varieties  are  again  divisible  into  those  which 
involve  the  viscera  and  those  in  which  the  organs  escape. 

Non-penetrating  Wounds  of  the  Abdominal  Walls. — Contusions  may 
involve  the  integument,  produce  extravasation  in  the  subcutaneous  tis- 
sues, rupture  of  the  muscles,  or  displacement  or  rupture  of  a  viscus  and 
death  without  any  external  evidence  of  injury. 

Bim,ple  contused  wounds  of  this  region  demand  no  especial  considera- 
tion. If  abscess  occurs,  the  same  rule  of  treatment  which  applies  to 
abscess  elsewhere  is  applicable  here.  Rupture  of  one  or  more  of  the 
miascles  may  occur  as  the  result  of  a  blow  on  a  muscle  in  tension,  or 
by  muscular  action  alone.  The  rectus  abdominalis  is  most  frequently 
torn.  Hernia  is  apt  to  follow  this  injury.  The  treatment  consists  in 
perfect  rest  and  well-adjusted  pressure  to  hold  the  viscera  within  the 
cavity  of  the  abdomen  until  cicatrization  can  take  place.  A  support- 
er should  be  worn  for  some  months  after  recovery,  or  permanently  if 
necessary. 


WOUNDS   OF  THE  ABDOMEN.  587 

Displacement  or  rupture  of  an  organ  (as  the  kidney,  spleen,  etc.)  may 
be  caused  by  direct  violence  or  by  a  severe  fall.  The  diagnosis  will,  in 
the  first  lesion,  depend  upon  the  absence  of  the  organ  from  its  normal 
place,  and  the  recognition  of  the  tumor  in  the  new  position.  Laceration 
is  followed  by  hfemon-hage,  at  times  profuse,  which  is  evident  from 
great  pallor  and  a  rapid  and  weak  pulse.  If  the  intestine  is  involved, 
the  escape  of  gas  or  ffeces  is  followed  usually  by  profound  shock,  tym- 
panites, and  peritonitis.  Emphysematous  crackling  may  be  recognized 
on  palpation. 

The  first  indication  in  treatment  of  a  displaced  viscus  is  to  place  the 
patient  in  such  a  posture  that  gravity  will  aid  in  the  restoration  of  the 
organ  to  its  normal  position.  A  compress  and  bandage  may  be  iiseful 
in  some  instances.  In  rupture  of  a  solid  organ,  profound  quiet  should 
be  maintained.  When  haemorrhage  is  alarming,  deligation  of  the  ex- 
tremities is  advisable.  Fluid  extract  of  ergot  hypodermically  may  be 
added.  If  the  symptoms  of  rupture  of  the  alimentary  canal  are  pres- 
ent, the  abdomen  should  be  opened  in  the  median  line,  the  rupture 
closed,  or  an  artificial  anus  established,  and  the  peritoneal  cavity  care- 
fully washed  out. 

Non-penetrating  incised,  punctured,  or  shot  wounds  of  this  region  do 
not  demand  especial  consideration.  The  former  should  be  closed,  while 
it  is  usually  safer  to  treat  the  punctured  and  shot  wounds  by  placing  a 
sublimate  compress  over  the  opening. 

Penetrating  Wounds. — AVounds  of  the  abdomen  which  penetrate 
without  wounding  any  internal  organ  should  be  closed  in  the  same  man- 
ner as  directed  for  the  closure  of  surgical  wounds  through  the  belly.  If 
an  internal  organ  is  involved,  the  abdomen  should  be  opened,  the  charac- 
ter of  the  lesion  ascertained,  and  proper  surgical  treatment  instituted. 
Among  the  symptoms  which  aid  in  arriving  at  a  diagnosis  are  the  follow- 
ing :  If  the  injury  is  followed  by  the  vomiting  of  blood,  it  is  fair  to  con- 
clude that  the  stomach  or  duodenum  is  involved  ;  if  blood  is  passed  by 
the  rectum,  that  the  wound  is  farther  along  the  bowel ;  or,  if  hpematuria 
exists,  that  the  kidney,  ureter,  or  bladder  is  injured.  If  the  odor  of 
intestinal  gas  or  faeces  is  present,  the  inference  is  clear  that  the  aliment- 
ary canal  is  opened.  BUe,  gastric  juice,  or  recently  ingested  matter  seen 
in  the  wound  or  recognized  by  the  sense  of  smell,  indicates  the  character 
of  the  injury  and  the  location  of  the  perforation.  The  crackling  sound 
peculiar  to  emphysema,  elicited  by  palpation,  indicates  the  presence  of 
intestinal  gas  in  the  loose  tissues,  beneath  the  peritonaeum  (Dennis). 
Tympanitic  resonance  over  the  liver,  which  has  appeared  suddenly  and 
which  is  persistent,  is  a  diagnostic  sign  of  perforation  of  considerable 
value.  Shock  is  usually  severe,  although  in  some  cases  it  may  be  slight 
and  of  short  duration. 

In  shot-wounds  the  location  of  the  wound  of  entrance  (and  exit,  if  it 
exists),  together  with  the  known  direction  of  the  missile  and  the  force 
with  which  it  was  propelled,  will  be  of  aid  in  determining  the  character 
of  the  lesion  within.  A  bullet  passing  directly  or  obliquely  into  the 
abdomen,  at  or  below  the  level  of  the  umbilicus  (Fig.  530),  can  scarcely 


588  A  TEXT-BOOK  ON  SURGERY. 

miss  the  intestinal  tnbe,  and  will  be  more  apt  to  make  a  number  of  holes 
than  a  single  wound.  Above  this  point  the  chances  of  escape  are  more 
favorable,  yet  so  fortunate  a  result  is  exceptional.  The  direction  and 
depth  of  a  stab- wound  may  also  be  determined  by  the  appearance  of  the 
wound  and  an  examination  of  the  instrument  with  which  it  was  inflicted. 
The  persistence  of  pain  in  a  given  point  within  the  abdomen  is  a  recog- 
nized symptom  of  a  penetrating  wound. 

Many  of  the  foregoing  symptoms  may  not  be  present  within  the  first 
few  hours  after  the  receipt  of  a  wound  which  has  penetrated  the  aliment- 
ary canal,  and,  beyond  tlie  external  wound  and  a  varying  degree  of  shock 
there  may  be  no  symptom  of  perforation.  Temporary  contraction  of  the 
muscular  fibers  of  the  stomach  or  intestine,  or  prolapse  of  the  mucous 
membrane  into  the  wound,  may  prevent,  for  a  time,  the  escape  of  gas  or 
ingested  matter,  and  the  appearance  of  the  more  pronounced  symptoms 
of  perforating  wounds  of  the  alimentary  canal. 

The  distention  of  the  alimentary  canal  by  hydrogen  gas  forced  into 
the  rectum,  as  advised  by  Senn,  in  order  to  determine,  by  the  escape  of  the 
gas  into  the  i^eritoneal  cavity  and  OTit  by  the  superficial  wound,  the  pres- 
ence of  a  penetrating  wound  of  the  intestine,  is,  in  my  opinion,  not  advis- 
able. In  wounds  of  small  aperture,  as  is  well  known,  escape  of  intes- 
tinal gas  or  other  contents  may  not  occur.  These  would  be  opened  by 
the  induction  of  gas,  and  extravasation  ensue.  When  doubt  exists, 
abdominal  section  and  direct  exploration  are  preferable. 

Treatment. — When  there  is  a  wound  in  the  wall  of  the  abdomen,  the 
immediate  indication  is  to  determine  whether  it  opens  into  the  cavity. 
In  order  to  do  this,  the  disinfected  finger,  or  the  light  and  porcelain-tipped 
Nelaton  probe,  should  be  introduced,  and,  if  necessary,  the  opening- 
should  be  enlarged.  Cocaine  anaesthesia  may  be  sufficient  for  this  pro- 
cedure. If  the  wound  is  confined  to  the  abdominal  wall,  it  should  be 
treated  in  the  aseptic  method  advised  for  ordinary  wounds  of  the  soft 
tissues.  If  it  extends  through  the  wall,  the  abdomen  should  be  opened, 
and  the  condition  of  the  viscera  examined.  As  to  whether  the  incision 
should  be  an  enlargement  of  the  accidental  wound,  or  made  in  the  median 
line,  the  location  and  direction  of  the  wound  must  determine.  The  sec- 
tion should  be,  preferably,  through  the  linea  alba.  If  the  lesion  is  not 
more  than  six  inches  from  this  line,  and  if  the  direction  of  the  wound  is 
backward  or  tending  toward  the  center,  the  median  incision  should  be 
chosen.  Under  other  conditions  the  section  may  be  through  the  wound 
of  entrance. 

In  this  procedure  the  details  of  the  antiseptic  method  should  be  car- 
ried out,  as  directed  in  operation  for  the  relief  of  intestinal  obstruction. 
When  the  peritoneal  cavity  is  opened,  if  it  contain  clotted  blood  which 
is  known  not  to  have  entered  from  the  wound  of  operation,  or  ingested 
matter,  or  if  gas  escape  thi'ough  the  opening,  the  penetrating  character 
of  the  wound  is  evident.  If  none  of  these  signs  are  present,  the  disin- 
fected hand  should  be  introduced  and  the  internal  surface  of  the  wall 
examined  at  the  supposed  point  of  entrance.  In  examining  the  intestinal 
canal,  it  is  advisable  to  begin  with  the  loops  of  smaU  intestine  which  pre- 


WOimDS   OF   THE  ABDOMEN. 


589 


sent  at  the  incision.  These  should  be  carefully  drawn  out  through  the 
opening,  and,  as  fast  as  inspected,  surrounded  with  towels  moistened  in 
warm  Thiersch  solution,  and  supj^orted  in  the  hands  of  an  assistant,  who 
will  not  allow  them  to  drag  heavily  upon  the  exposed  mesentery.  If  an 
opening  be  found  in  the  gut,  it  may  be  at  once  closed,  or  noted  and 
passed  over  until  the  entire  canal  and  cavity  have  been  examined.  If  a 
cutting  or  puncturing  sharp  instrument  has 
inflicted  the  wound,  its  edges  will  be  found 
sufficiently  smooth  to  be  sutured  at  once, 


Fig.  549. — Pistol-shot  wound  of  small  intestiue.     (After  Bull.) 


Fig.  548. — Lembert's  suture  for  clos- 
ing wounds  of  the  intestines. 
(Alter  Esmarch.) 


and  should  be  brought  together  by  Lem- 
bert's suture  (Fig.  548).  If  the  hole  has  been 
made  by  a  bullet,  and  has  rough  and  torn  borders,  as  in  Fig.  .549,  its 
edges  should  be  trimmed  smooth,  with  curved  scissors,  and  then  closed. 
When  only  a  narrow  strip  of  tissue  separates  two  openings  (Fig.  549), 
they  should  be  converted  into  a  single  elliptical  wound,  and  sutured. 
The  proper  distance  of  the  sutures  from  each  other  is  shown  in  Fig.  548. 
While  the  sutures  are  being  inserted,  the  intestine  should  be  laid  upon 
towels  spread  over  the  abdomen,  near  the  incision.  The  escape  of  fecal 
matter  into  the  cavity  of  the  peritoneeum  should  be  prevented  by  flat 
sponges  j)laced  around  the  margins  of  the  wound.  If  the  wound  in  the 
wall  of  the  gut  is  so  extensive  that,  in  closing  it,  the  lumen  of  the  tube 
will  be  seriously  constricted,  the  injured  portion  should  be  exsected. 
After  all  wounds  are  stitched  and  haemorrhage  is  arrested,  the  cavity  of 
the  peritongeum  should  be  carefully  cleansed.  This  is  effected  by  sponges, 
attached  to  holders,  carried  into  all  parts  of  the  cavity.  AVhen  fecal 
extravasation  has  occurred,  it  will  be  advisable  to  flood  the  entire  cavity 
with  warm  Thiersch's  solution,  remove  it  with  sponges,  and  repeat  the 
irrigation  until  the  liquid  comes  away  free  from  odor  or  color.  A  drain- 
age-tube should  be  employed  in  this  worst  class  of  cases.  The  Sims  tube 
is  to  be  preferred,  and  the  end  of  this  should  be  carried  down  to  the  most 
dependent  portion  of  the  cavity  (usually  in  the  pelvis,  in  the  cul-de-sac). 
The  method  of  employing  this  excellent  instrument  is  described  in  the 
article  on  ovarian  tumors. 

The  intestines  should  now  be  returned  and  the  wound  closed.  Irriga- 
tion through  the  drainage-tube  may  be  made  when  indicated  by  the  tem- 
perature, tympanites,  etc. 


590  A  TEXT-BOOK  ON  SURGERY. 

No  especial  treatment  can  be  laid  down  for  wounds  of  the  solid  vis- 
cera or  of  the  great  vessels.  The  arrest  of  haemorrhage,  the  removal  of 
extravasated  blood,  and  the  establishment  of  drainage  when  needed,  are 
the  indications. 

The  argument  in  favor  of  operative  interference  in  penetrating  or 
supposed  penetrating  wounds  of  the  abdomen  may  be  briefly  stated,  as 
follows : 

1.  The  enlargement  of  a  wound  sufficiently  to  demonstrate  its  opening 
(or  not  opening)  into  the  cavity  of  the  peritonseum  is  a  simple  procedure, 
practically  without  danger. 

2.  Abdominal  section  is  not  a  difficult,  nor,  when  skillfully  and  prop- 
erly performed,  a  dangerous  operation. 

3.  A  penetrating  wound  of  the  abdomen,  left  without  surgical  inter- 
ference, is  attended  always  with  great  danger. 

4.  If  any  vessels  of  size  are  divided,  haemorrhage  is  an  immediate 
danger,  and  peritonitis  a  serious  and  probably  fatal  complication. 

5.  If  the  alimentary  canal  is  opened,  death  is  almost  inevitable.  The 
few  recorded  cases  of  I'ecovery  form  such  an  infinitesimal  proportion  of 
the  whole,  that  they  should  carry  no  weight  against  interference. 


i 


CHAPTEE  XVIII. 

PELVIC   ORGANS. 


RECTUM  AND   ANUS — GENITO-URINARY  ORGANS. 

Diseases  of  the  Rectum  and  Anus — Congenital  Defects. — Arrest  of 
development  in  the  rectal  and  anal  portions  of  the  alimentary  canal, 
though  not  so  frequent  as  at  the  upper  or  buccal  extremity,  is  unfortu- 
nately common  enough  to  justify  a  consideration  of  the  different  kinds 
of  deformity  which  may  here  be  met  with,  and  the  mode  of  treating 
them. 

Absence  of  the  anus  is  one  of  the  most  frequent  congenital  lesions  of 
the  alimentary  outlet.  The  rectum  may  be  partially  developed,  and  ter- 
minate within  the  pelvis  in  a  blind  pouch  at  a  point  more  or  less  re- 
moved from  the  normal  opening  (Fig.  550) ;  there  may  be  a  partial  de- 


Fio.  550. — Atresia  of  the  anus. 
(After  Esmarch.; 


Fig.  551. — Atresia  of  tbe  rectum,  with  a  rudi- 
mentary anus.    (After  Esinarch.) 


velopment  of  the  anus  (Fig.  551) ;  or  the  rectum  may  be  entirely  absent 
(Fig.  552) ;  or  it  may  be  present  in  the  pelvis,  opening  abnormally  into 
the  bladder,  vagina,  uterus,  or  urethra  (Figs.  553  and  554).  In  the  sim- 
pler forms  of  atresia  ani  only  a  thin  membrane  is  stretched  across  the 
otherwise  normal  opening.     The  more  complicated  varieties  are  those 


592 


A  TEXT-BOOK   ON   SURGERY. 


in  which  a  greater  distance  intervenes  between  the  end  of  the  defective 
intestine  and  the  perinseum. 

Diagnosis. — Absence  of  the  anus  is  easily  established  by  inspection. 
The  more  important  and  difficult  point  is  to  determine  the  distance  from 


Fig.  552. — Atresia  of  the  anus  and  rectum. 
(After  Esmarc'h.) 


Fio.  553. — Atresia  of  the  anus  and  lower  portion 
of  the  rectum  ;  the  upper  part  opening  into  the 
urethra.     (After  Eamarch.) 


the  perinseum  to  the  end  of  the  pouch. 
When  the  intervening  tissue  is  thin, 
the  accumulation  of  matter  within  the 
tube  may  cause  a  protrusion  in  the 
peringeum  which  is  exaggerated  when 
the  infant  cries.  If  the  finger  be 
pressed  into  the  perinteum,  an  im- 
pulse somewhat  comparable  to  that 
felt  in  the  expulsive  efforts  of  a  pa- 
tient with  hernia  may  be  appreciated. 

Exploration  by  the  vagina,  when 
the  capacity  of  this  tube  will  permit, 
will  aid  in  diagnosis. 

When  the  intestine  opens  into  an- 
other hollow  organ,  or  through  the 
integument  in  an  abnoi'mal  position, 
the  only  diagnostic  sign  is  the  pres- 
ence of  fecal  matter  in  the  natural 

discharge  from  the  organ  or  at  the  abnormal  opening.  In  atresia  recti 
in  female  children,  the  bowel  opens  most  frequently  into  the  uterus  or 
vagina,  and  in  males  into  the  bladder.  At  times  the  communication  is 
established  between  the  bowel  and  the  urethra,  or  a  false  opening  may 
occur  at  any  point  in  the  perineeum,  and,  in  rarer  cases,  in  some  remote 
portion  of  the  body. 


Fig.  554. — The  same  j  the  upper  portion  of  the 
rectum  opening  into  the  bladder.  (After 
Esmarch.) 


PELVIC   ORGANS.  593 

Treatment. — The  indications  are  to  establish  an  o]pening  as  near  the 
natural  position  of  the  anus  as  possible.  If  the  blind  pouch  can  be  reached 
by  the  exploring  aspirator,  the  needle  should  be  left  in  place  as  a  guide. 
The  operative  procedure  is  to  dissect  gradually  toward  the  sujjposed 
location  of  the  end  of  the  gut,  keeping  an  open  and  clear  wound  by  using 
retractors  and  arresting  all  hfemorrhage.  The  incision  through  the  in- 
tegument should  be  in  the  median  line,  with  its  center  Just  in  front  of 
the  tip  of  the  sacrum  and  coccyx,  for,  if  the  spliincter  ani  is  present, 
even  in  an  imperfect  condition,  it  is  important  to  preserve  it  to  aid  in 
the  voluntary  control  of  the  bowel  when  the  operation  is  completed. 
When  there  exists  only  a  thin  septum,  this  muscle  is  usually  well  de- 
veloped, and  the  operation  is  a  simple  incision  and  divulsion  of  the  mem- 
brane. In  more  formidable  operations,  the  location  of  the  urethra  and 
bladder,  and  in  females  the  vagina  and  uterus,  must  be  kept  well  in 
mind,  for  in  infants  the  pelvic  diameters  are  very  small,  varying  from 
one  to  one  and  a  half  inch.  It  is  a  safe  rule  to  proceed  cautiously 
along  the  sacral  curve.  Moreover,  it  is  wiser  to  dispense  with  an  anses- 
thetic,  since  the  expulsive  efforts  in  crying  may  aid  in  iinding  the  end 
of  the  gut. 

When  it  is  reached,  if  it  is  possible,  the  end  should  be  loosened, 
drawn  down,  and  sutured  to  the  integument  at  the  edges  of  the  incision. 
If  this  is  not  done,  the  opening  usually  contracts,  necessitating  repeated 
dilatation  by  the  use  of  the  finger,  tents,  or  a  divulsor.  In  some  in- 
stances it  has  been  found  necessary  to  remove  the  coccyx  in  order  to 
effect  the  union  of  the  bowel  with  the  skin. 

When,  after  proceeding  as  far  as  the  immediate  safety  of  the  infant 
will  justify,  the  bowel  can  not  be  discovered,  the  propriety  of  colostomy 
or  enterostomy  may  be  entertained.  If  determined  upon,  right  lumbar 
colostomy  is  indicated,  on  account  of  the  probability  of  absence  or  mal- 
position of  the  descending  colon.  When  the  intestine  ends  directly  in 
the  uterus  or  vagina,  and  there  is  no  i)ouching  behind  these  organs  to- 
ward the  perinseum,  it  is  best  not  to  interfere.  If,  however,  the  bladder 
or  urethra  is  involved,  an  opening  should  be  made  or  colostomy  per- 
formed. 

In  exceptional  cases  the  anus  is  present  in  a  condition  of  more  or  less 
perfect  development,  while  at  the  same  time  the  rectum  does  not  com- 
municate with  it,  but  terminates  in  a  blind  pouch  at  a  varying  distance 
from  the  perinseum. 

The  effort  should  be  made  to  establish  a  communication  between  the 
two  pockets  by  dissection  through  the  tissues  which  intervene. 

When  the  opening  from  the  rectum  is  abnormally  small  (a  congenital 
stricture),  dilatation,  incision,  or  diviilsion  should  be  performed. 

The  unfavorable  prognosis  in  all  these  cases  should  not  be  concealed. 
Inflammation,  visceral  complications,  dilatation  of  the  bowel  above  with 
retained  ingesta,  insufficient  assimilation,  i^ain,  etc.,  render  a  favorable 
issue  exceedingly  improbable. 

Pruritus  Ani. — Persistent  itching  aboiit  the  anus  may  be  caused  by 
a  variety  of  skin-diseases,  as  eczema,  herpes,  pityriasis,  and  erythema, 

38 


594  A  TEXT-BOOK   ON   SURGERY. 

or  by  irritation  of  the  end-organs  of  tlie  sensory  nerves  from  over- dis- 
tention in  the  act  of  defecation.  It  is  also  a  symptom  of  hgemorrlioids, 
fissure  of  tiie  anus,  or  may  be  due  to  the  presence  of  the  thread-worm 
{ascaris  vermicularis).  The  character  of  the  itching  is  burning,  pain- 
ful, and  aggravating,  and  the  desire  to  scratch  is  almost  irresistible.  The 
successful  management  of  pruritus  ani  will  depend  upon  the  recognition 
of  the  disease  of  which  it  is  a  symptom. 

Eczema  of  the  perineum  and  anus  is  more  apt  to  occur  in  a  warm 
temperature,  where  perspiration  is  excessive,  and  in  corpulent  individ- 
uals where  considerable  friction  occurs  between  the  folds  of  integument 
of  this  region.  The  skin  becomes  inliltrated  and  thickened,  fissures  are 
formed,  and  the  mucous  membrane  at  the  anal  opening  may  become  in- 
volved. 

Treatment. — The  part  affected  should  be  kept  clean  and  friction  pre- 
vented as  much  as  possible.  In  the  acute  eczema  of  the  anal  region  a 
warm  bath,  without  soap,  should  be  taken  two  or  three  times  a  day,  the 
parts  thoroughly  dried,  and  sprinkled  with  powdered  starch  or  lycopo- 
dium.  If  excoriations  exist,  lead-and-opium  wash  should  be  tried.  In 
chronic  eczema  of  the  anus,  in  order  to  effect  a  cure,  it  is  often  necessary 
to  remove  the  accumulation  of  scales  by  the  local  use  of  green  soap  for 
a  day  or  two,  and  then  smearing  the  surface  with  diachylon-salve. 

Herpes  may  be  recognized  by  the  character  of  the  erui^tion,  which  is 
vesicular,  the  vesicles  being  grouped  in  bunches  around  the  anus.  Those 
which  rupture  and  are  subjected  to  irritation  present  flat  and  slightly 
ulcerating  excoriations.  The  treatment  consists  in  thoroughly  washing 
the  surface  involved  with  a  wann  solution  of  boracic  acid,  gi-s.  xv-  3  j 
of  water,  by  means  of  pellets  of  absorbent  cotton  moistened  in  the  solu- 
tion. This  should  be  followed  by  applying  an  astringent  ointment,  com- 
posed as  follows :  plumbi  acetatis,  grs.  iij ;  acid,  tannic,  gr.  j ;  morphise 
sulph.,  grs.  iij;  adipis,  §j. 

Erythema  is  a  mild  form  of  inflammation  of  the  integument,  occur- 
ring here  as  a  result  of  friction  between  the  folds  of  skin  of  the  two  sides 
and  the  irritation  from  persj)iration  or  other  fluids.  The  warm  bath,  fol- 
lowed by  sprinkling  the  part  affected  with  starch  or  lycopodium,  wiU. 
usually  effect  a  cure. 

Pityriasis  versicolor  occasionally  exists  in  the  ischio-rectal  region. 
This  disease  can  be  recognized  by  the  brownish  slate-color  of  the  parts 
involved.  The  cause  is  a  vegetable  parasite,  the  spores  and  mycelia  of 
which  may  be  easily  recognized  by  the  microscope.  It  yields  readily  to 
pure  sulphurous  acid,  which  may  be  applied  by  means  of  a  camel's-hair 
pencil.  Corrosive  sublimate  (gr.  j  to  water  ^  j)  may  be  applied  by  wi-ap- 
ping  the  parts  with  absorbent  cotton  dipped  in  this  solution. 

When  pruritus  occurs  with  hjemorrhoids  or  fissure,  the  treatment 
must  be  directed  to  these  affections.  If  it  is  caused  by  over-distention 
or  irritation  of  the  rectum  and  anus,  the  use  of  enemata  and  laxatives 
will  arrest  the  disease.  The  local  application  of  a  4-per-cent  solution  of 
cocaine  hydrochlorate  will  dull  the  sensibility  of  the  part  and  tempo- 
rarily stop  the  pain  and  itching. 


FISTULA   OF   THE   ANUS   AND   RECTUM.  595 

Ascai'ides,  or  "thread-worms,"  are  not  an  uncommon  cause  of  pru- 
ritus ani.  They  vary  in  length  from  a  quarter  to  half  an  inch,  are  some- 
what lighter  in  color  than  the  mucous  membrane,  and  are  not  readily 
seen  unless  this  membrane  is  everted  and  carefully  examined.  Santo- 
nin in  full  doses  should  be  administered  for  two  or  three  days,  followed 
by  a  free  purgation.  When  this  is  accomplished  the  bowel  should  be 
distended  with  an  enema  of  lime-water,  retained  for  fifteen  minutes,  if 
possible,  and  repeated.  As  soon  as  the  last  injection  is  evacuated,  a 
pint  of  water,  in  which  grs.  xx  of  carbolic  acid  are  thoroughly  dissolved, 
should  be  thrown  into  the  rectum  and  retained  for  about  five  minutes. 
The  injection  of  lime-water  and  carbolic  acid  in  solution  should  be  re- 
peated for  several  days  to  insure  a  thorough  destruction  of  these  annoy- 
ing parasites. 

Enemata  of  the  infusion  of  quassia  are  also  highly  recommended  in 
the  extermination  of  the  ascaris  vermicularis. 

Foreign  Bodies. — Foreign  bodies  in  the  rectum  are  usually  intro- 
duced through  the  anus,  and  not  infrequently  lodge  here,  having  passed 
through  the  alimentary  canal.  Their  presence  may  be  recognized  by 
digital  exploration,  or,  when  of  small  size,  the  speculum  may  be  em- 
ployed. 

Digital  exploration  of  the  rectum  may  be  performed  with  the  mini- 
mum of  discomfort  by  curving  the  thoroughly  lubricated  finger  to  con- 
form to  the  shape  of  the  lower  portion  of  the  bowel.     The  direction  from 

the  anus  is  upward  and  for- 
ward for  the  first  inch  and  a 
half,  and  then  upward  and 
slightly  backward. 

If  a  speculum  is  employed, 
that  of  Sims  (Fig.  555)  should 
be  preferred. 

A    small    body   may  be 
„     ,.^    „.    ,       ,  ,        ,  readily  removed   by  seizing 

Fig.  5o5. — Sims's  rectal  speculum.  •'  ./  o 

it  with  a  long  forceps  after 
dilatation  with  this  instru- 
ment. A  large  substance  may  require  anaesthesia,  with  forcible  divul- 
siori  of  the  sphincter,  or  a  posterior  linear  rectotomy  before  it  can  be 
removed.  When  the  object  is  made  of  glass  or  any  fragile  substance, 
great  care  should  be  taken  to  prevent  its  breaking. 

Fistula  in  Ano. — A  fistula  of  the  anus  or  rectiim  may  be  complete  or 
incomplete.  The  last  variety  is  further  divided  into  the  incomplete  ex- 
ternal and  the  incomplete  internal  fistula. 

In  the  complete  form  the  track  of  the  fistula,  more  or  less  sinu- 
ous, leads  from  the  wall  of  the  rectum  or  the  anal  margin  out  through 
the  integument  of  the  perineal,  ischio-rectal,  or  gluteal  regions  (Fig. 
556).  In  the  incomplete  external  variety,  the  track  opens  through  the 
skin,  but  does  not  communicate  with  the  rectum  (Fig.  557)  ;  while  m 
the  incomplete  internal  fistula  the  track  opens  into  the  bowel  only 
(Fig.  558). 


596 


A  TEXT-BOOK   ON   SURGERY. 


The  chief  causes  of  peri-rectal  abscess  are  the  irritation  which  follows 
the  lodgment  of  fecal  matter  and  undigested  substances  in  the  rectum  ; 
the  over-distention  of  this  organ  as  a  result  of  constipation  ;  the  presence 
of  hgemorrhoidal  tumors ;  the  introduction  of  hard  bodies,  as  the  nozzle 
of  a  syringe,  etc.,  through  the  anus  ;  and,  lastly,  direct  injury  by  a  blow 
from  without.  Abscess  in  this  region  occurs  by  preference  in  the  weak 
and  debilitated,  in  those  suffering  from  the  tubercular  diathesis,  and 
is  rarely  met  with  before  the  twenty-iifth  year  of  life. 


— (     1 1 1  t    t  tuU 
in  recto. 


Fig    557  — In     mj  ktc  external 
ll^tula. 


J? IG    55S  — Inc  mi  lete 
inteiual  iibtula. 


Suppuration  begins  as  a  rule  in  the  loose  areolar  tissue  around  the 
rectum.  Although  the  inflammation  may  originate  in  the  mucous  mem- 
brane and  wall  of  the  bowel,  perforation  of  the  wall  is  rare  until  the 
process  of  sujjpuration  is  well  established  in  the  connective  tissues  of 
the  ischio-rectal  fossa.  As  the  pus  accumulates  the  tissues  break  down, 
and  the  abscess  opens  into  the  bowel  or  through  the  integument.  A 
complete  fistula  may  be  developed  from  either  of  the  incomplete  varieties 
by  partial  occlusion  of  the  original  opening,  thus  causing  the  pus  to  seek 
an  outlet  elsewhere. 

Abscess  of  this  region  may  be  superficial  or  deep.  When  superficial, 
it  is  apt  to  open  through  the  mucous  membrane,  just  above  the  junction 
of  the  skin  and  mucous  membrane.  When  the  deep  variety  opens  into 
the  rectum,  it  is  usually  at  a  point  from  three  fourths  of  an  inch  to  two 
inches  from  the  margin  of  the  anus.  A  single  abscess  may  have  one  or 
more  openings  into  the  rectum  or  through  the  skin. 

The  diagnosis  of  fistula  in  ano  is  not  difficult.  It  depends  upon  the 
history  of  an  abscess  followed  by  a  constant  or  frequently  recurring  dis- 
charge of  pus,  the  pain  being  severe  until  the  abscess  is  evacuated,  and 
recurring  in  a  varying  degree  with  the  temporary  closure  of  the  out- 
let. An  area  of  induration  usually  exists,  and  the  opening  may  be  dis- 
covered either  through  the  skin  or  within  the  aniis.  If  an  external 
opening  exists  through  which  gas  or  fecal  matter  escapes,  a  complete 
fistula  is  demonstrated.  AVhen  an  external  opening  is  formed,  unless 
the  abscess  is  very  recent,  there  is  almost  always  an  internal  opening, 
although  it  may  not  be  found.  The  diagnosis  may  be  further  made  clear 
by  exploration  with  a  probe,  an  operation  which  is  rendered  practically 
painless  by  the  injection  of  a  4-per-cent  solution  of  cocaine  hydrochlo- 
rate  into  the  abscess  cavity.  If  a  single  injection  does  not  svifiiciently 
dull  the  sensibility,  it  should  be  re^Deated. 

No  matter  where  the  external  opening  is  situated,  the  track  will,  in 
the  great  majority  of  instances,  run  just  beneath  the  skin  toward  the 
anus.     The  probe  should  be  allowed  almost  to  find  its  own  way,  and. 


FISTULA    OF   THE   ANUS   AND   RECTUM.  597 

when  well  in,  the  point  at  which  it  imj)inges  upon  or  opens  into  the 
bowel  can  be  determined  by  the  finger  in  the  rectum. 

The  treatment  should  be  by  free  incision.  In  mild  cases  local  anaes- 
thesia, obtained  by  cocaine,  is  sufficient.  One  or  two  hypodermic  syringes 
fall  of  a  4-per-cent  solution  should  first  be  thrown  into  the  cavity  of  the 
sinus,  and  the  direction  of  the  opening  into  the  bowel  determined  by  the 
probe  or  grooved  director.  The  cocaine  should  then  be  injected  into 
the  tissues  by  repeated  introductions  of  the  needle  in  the  line  of  the 
proposed  incision  into  the  bowel.  Thirty  minims  of  this  solution  are 
usually  sufficient  in  this  last  procedure,  but  as  many  as  sixty  may 
be  injected  if  necessary.  Of  the  quantity  thrown  into  the  abscess  only 
a  small  proportion  is  absorbed,  while  of  that  injected  into  the  tissues 
the  larger  part  escapes  with  the  blood  which  follows  the  incision. 
When  the  sinus  is  long  and  the  cavity  of  the  abscess  extends  more  than 
one  inch  above  the  anus,  the  operation  should  be  performed  under  ether 
narcosis. 

Operation. — A  laxative  should  be  administered  the  day  before  the 
operation,  and  an  enema  given  two  hours  before  the  ansesthetic.  The 
perinseum  and  region  of  the  anus  should  be  cleanly  shaved.  The  patient 
should  be  placed  upon  the  back,  with  the  sacrum  resting  on  the  edge 
of  the  table,  the  legs  flexed  on  the  thighs,  and  the  thighs  on  the  abdo- 
men, and  separated  ;  or  upon  the  side  in  the  Sims  position.  The  probe 
should  be  carried  into  the  fistula,  the  lubricated  index-finger  of  the 
left  hand  into  the  rectum,  and  the  point  noted  at  which  the  instrument 
strikes  the  rectum.  The  probe  is  now  withdrawn,  and  the  grooved  di- 
rector introduced  in  the  same  track.  If  the  opening  into  the  bowel  can 
not  be  found,  the  operator  should  determine  by  the  touch  the  thinnest 
point  on  the  intervening  wall,  and  at  this  location  bore  through  into  the 
rectum,  supporting  the  mucous  membrane  near  the  point  of  the  instru- 
ment with  the  finger  in  the  bowel.  As  soon  as  the  director  is  felt  in  the 
cavity  of  ihe  gut,  the  point  should  be  brought  out  at  the  anus,  the  sharp- 
pointed  curved  bistoury  carried  along  the  groove,  and  the  fistiila  laid 
open  by  dividing  the  intervening  bridge  of  tissue.  If  a  second  sinus 
exists,  it  should  be  incised  in  the  same  way.  The  bleeding  is  usually 
insignificant,  and  may  be  arrested  by  pressure,  or  the  ligature.  The 
finger  should  now  be  carried  into  the  wound,  and,  if  it  is  discovered  that 
the  abscess  extends  higher  along  the  wall  of  the  rectum  than  the  point 
at  which  the  director  was  carried  through,  the  intervening  wall  should 
be  divided  with  the  blunt  scissors.  It  is  important  that  the  incision  in 
the  gut  should  extend  to  the  depth  of  the  abscess  when  this  point  is 
less  than  three  inches  from  the  anus.  A  careful  search  for  any  pockets 
or  sinuses  should  be  made,  and  these,  if  found,  should  be  laid  freely 
open.  The  fistulous  track  should  now  be  scraped  out  with  the  sharp 
spoon,  and  the  entire  wound  packed  with  sublimate  gauze  held  in  place 
by  a  compress  and  T-bandage.  This  dressing  should  be  allowed  to  re- 
main in  place  for  two  or  three  days,  when,  with  the  first  evacuation  of  the 
bowels,  it  is  carried  away.  After  this  the  wound  is  not  repacked,  but, 
for  purposes  of  cleanliness,  it  may  be  washed  out  by  allowing  the  patient 


598  A  TEXT-BOOK   ON  SURGERY. 

to  sit  in  a  basin  of  warm  water  once  or  twice  a  day,  or  by  irrigation,  and 
an  outside  dressing  apj)lied. 

The  wound  rapidly  teals  by  granulation,  and,  in  the  vast  majority 
of  cases,  a  cure  is  effected  by  a  single  operation.  Temporary  inconti- 
nence of  faeces  results  in  all  cases  where  both  sphincters  are  divided,  but 
a  i^ermanent  loss  of  function  is  exceptional.  It  is  more  apt  to  occur  in 
females,  and  for  this  reason  a  more  guarded  prognosis  should  be  made 
in  this  class  of  patients.  In  the  rare  instances  in  which  an  internal  in- 
complete fistula  is  present,  the  cavity  of  the  abscess  should  be  opened 
by  incision  through  the  skin,  and  the  operation  completed  as  just  given. 

A  division  of  the  external  sphincter  is  not  necessary  in  the  mildest 
class  of  cases,  in  which  the  abscess  is  recent  and  small,  and  in  which  the 
sinus  runs  just  beneath  the  skin  and  opens  at  the  margin  of  the  anus. 
Under  all  other  conditions  it  should  be  partially  or  completely  divided. 

The  immediate  closure  of  the  fistulous  track  is  an  operation  which 
has  been  recently  performed  in  a  number  of  instances.  After  the  fistula 
is  incised,  the  wall  of  the  abscess  is  dissected  out  and  the  two  perfectly 
healthy  surfaces  are  brought  together  with  sutures. 

An  older  method  consists  in  the  introduction  of  an  elastic  ligature 
through  the  external  opening  into  the  bowel  and  out  through  the  anus, 
where  the  ends  are  tied  together.  The  loop  is  allowed  to  cut  through 
slowly,  and  it  may  be  necessary  to  tighten  it  from  time  to  time. 

PropJiylaxis. — Upon  the  first  appearance  of  inflammation  in  the 
ischio-rectal  or  perineal  region,  the  integument  immediately  over  the 
most  superficial  point  of  the  induration  should  be  incised,  and  a  fi'ee 
puncture  made  into  the  inflamed  tissues.  This  should  be  followed  by 
the  application  of  poultices  and  complete  rest  in  the  recumbent  post- 
ure. Too  great  distention  of  the  rectum  should  be  prevented  by  the 
administration  of  laxatives,  and  an  enema  of  warm  water  should  be 
given  just  before  the  bowel  is  emptied.  By  this  method  the  tension  is 
relieved  and  an  outlet  given  to  the  products  of  inflammation  before  the 
process  extends  into  the  deeper  tissues.  A  cure  without  further  ojDera- 
tion  will  be  effected  in  a  fair  proportion  of  cases. 

After  an  abscess  is  once  formed,  whether  the  fistula  opens  into  the 
rectum  or  through  the  integument,  or  has  both  outlets,  the  case  demands 
operative  interference.  The  proportion  of  cures  by  the  use  of  injections 
into  the  fistula,  or  the  application  of  stimulating  remedies,  is  so  very 
smaU  and  such  valuable  time  is  lost,  that  their  employment  is  unjusti- 
fiable. Of  the  radical  operations,  preference  should  always  be  given  to 
that  of  free  incision.  The  elastic  ligature  should  only  be  tried  on  pa- 
tients who  are  unwilling  to  remain  in  bed,  or  to  be  operated  upon  with 
the  knife,  to  whom  the  merits  of  the  two  operations  have  been  explained, 
and  who  relieve  the  surgeon  of  the  probabilities  of  failure.  It  is  also 
applicable  to  those  cases  in  which  the  fistula  enters  the  rectum  so  high 
up  that  incision  is  impracticable.  A  guarded  prognosis  should  be  made 
in  this  class  of  patients. 

Operation  by  immediate  closure  should  not  be  preferred  to  the  open 
method,  for  the  reasons  that  the  old  operation  cures  almost  all  cases, 


FISSURE  AND  ULCER   OF   THE  ANUS   AND   RECTUM.       599 

and  is  easy  of  execution.  The  new  method  is  more  diflBcnlt,  and  is  only 
applicable  to  the  milder  cases.  The  failure  to  close  even  a  small  part  of 
the  wound  in  the  rectal  wall  would  insure  failure,  while  a  like  result 
would  be  apt  to  follow  if  the  entire  wounded  surfaces  were  not  in  perfect 
coaptation.  This  operation  would  be  apjjlicable  in  those  cases  where,  as 
a  result  of  incision,  there  was  serious  impairment  in  the  function  of  the 
sphincter  ani. 

Operative  interference  is  contraindicated  in  multiple  fistulse  in  the 
aged,  or  in  patients  in  a  weak  and  debilitated  condition.  When  the 
tubercular  diathesis  is  well  marked,  an  operation  should  not  be  done 
unless  great  discomfort  is  caused  by  the  fistula,  and,  when  performed, 
the  prognosis  should  be  guarded. 

Fissure. — Fissure  of  the  anus  is  most  frequently  met  with  on  the 
posterior  portion  of  the  outlet.  It  may,  however,  exist  at  any  part  of 
the  anal  circumference,  or  in  the  rectum  above  the  sphincter.  The  tear 
is  usually  tWough  the  mucous  membrane,  although  the  muscular  fibers 
may  be  more  or  less  involved.  The  chief  cause  is  over-distention  of  the 
amis  in  the  evacuation  of  hardened  fseces,  together  with  the  presence  of 
sharp  substances  in  the  matter  discharged.  In  like  manner,  foreign 
bodies  introduced  into  the  rectum  may  produce  it.  Fissure  may  result 
from  the  inflammation  and  ulceration  of  a  hsemorrhoid,  or  from  any 
chronic  inflammatory  process  in  the  rectum. 

The  chief  symptom  is  pain  of  an  acute  character,  exaggerated  by  an 
evacuation  of  the  bowel,  and  continuing  some  time  after  the  act  in  a 
violent  spasm  of  the  sphincter  muscle.  By  careful  and  gentle  dilata- 
tion of  the  anus,  it  may  be  seen  or  recognized  by  the  touch  as  a  line  of 
induration  running  parallel  with  the  axis  of  the  bowel.  The  employment 
of  cocaine  will  render  the  exploration  more  thorough,  and  will  permit 
the  introduction  of  the  speculum. 

Treatment. — The  administration  of  laxatives,  and  the  employment  of 
enemata  of  warm  water  and  olive-oil,  will  remove  the  chief  source  of 
irritation,  while  the  stimulating  effect  of  the  lunar-caustic  pencil  applied 
in  the  fissure,  and  repeated  every  two  or  three  days,  will  usually  effect  a 
cure.  Cocaine  should  be  employed  to  deaden  the  sensibility  before  the 
silver  is  applied.  If  a  more  radical  procedure  is  necessary,  it  will  con- 
sist in — 1,  a  partial  division  of  the  sphincter  in  the  line  of  the  fissure ; 
or,  2,  temporary  paralysis  of  this  muscle  by  divulsion. 

As  the  second  operation  requires  ether  narcosis,  the  partial  division 
should  be  first  employed.  In  its  performance  local  anaesthesia  should 
be  obtained  by  the  application  of  4-per-cent  cocaine  to  the  inflamed  sur- 
face, together  with  the  injection  of  this  fluid  by  introducing  the  needle 
just  beneath  the  fissure  in  its  entire  extent.  The  sphincter  should  now 
be  made  tense  by  separating  the  sides  of  the  speculum,  and  an  incision 
made  through  the  depth  of  the  fissure,  dividing  about  half  of  the  thick- 
ness of  the  muscle.  In  the  after-treatment,  the  bowels  should  be  kept 
open.  Divulsion  of  the  sphincter  is  performed  as  follows :  The  patient, 
fuUy  anaesthetized,  is  placed  upon  the  back,  with  the  thighs  separated 
and  flexed   on   the  abdomen.      The   operator,    having  lubricated  both 


600  A  TEXT-BOOK   ON   SURGERY. 

tlinmbs,  introduces  one  and  then  the  other  to  their  full  length,  and 
stretches  the  opening  directly  to  the  right  and  left  until  the  palmar  as- 
pect of  each  thumb  is  in  contact  with  the  inner  surface  of  the  tuber 
ischii.  A  towel,  held  in  place  by  a  roller  or  T-bandage,  should  be  applied 
to  prevent  soiling.  The  rest  obtained  by  the  paralysis  of  the  sj)hiiicter 
allows  the  fissure  to  heal.  The  function  of  the  muscle  is  restored  in 
from  eight  to  twelve  days. 

Ulcers. — The  traumatic  causes  of  ulcer  of  the  rectum  are  the  same 
as  those  given  for  fissure  of  the  anus.  Ulcer  may  also  result  from  any 
acute  or  chronic  inflammatory  process  of  the  lower  bowel.  It  is  a 
not  infrequent  sequence  of  dysentery,  and  may  be  met  with  in  that 
form  of  proctitis  which  results  from  prolonged  diarrhoea.  Inflamma- 
tion of  a  hsemorrhoidal  tumor  will  produce  ulcer  of  the  rectum,  and 
the  same  is  true  of  the  gummatous  deposits  of  the  late  stages  of  syph- 
ilis. A  primary  chancre  or  a  chancroid  may  be  located  at  the  anal 
margin,  and  less  frequently  in  the  bowel.  These  two  varieties  of  ulcer 
are  usually  seen  in  women  suifering  with  pudendal  chancre  or  chan- 
croid, and  in  males  the  subjects  of  pederasty.  Tubercular  deposits  in 
the  rectum  may  also  break  down,  and  thus  cause  ulceration  in  the  wall 
of  this  organ. 

The  symptoms  of  ulcer  of  the  rectum  vary  with  the  character  of  the 
sore  and  with  its  location.  If  the  lesion  is  situated  within  the  grasp  of 
the  sphincter  muscles,  tenesmus  is  apt  to  be  a  marked  feature.  The 
ulcer  from  a  traumatism,  or  following  an  acute  inflammatory  process, 
is  more  apt  to  be  painful  than  that  which  is  a  part  of  a  subacute  or 
chronic  catarrh,  or  which  occurs  with  tuberculosis  or  syphilis.  A  com- 
mon symptom  of  all  ulcers  of  this  organ  is  the  presence  of  more  or  less 
blood  and  mucus  or  pus  in  the  discharges.  The  diagnosis  may  be  con- 
firmed by  inspection  with  the  speculum,  and  by  digital  exjsloration. 
Tubercular  ulcer  of  the  rectum  very  rarely  exists  before  the  symptoms 
of  deposits  in  the  lungs  are  present.  Upon  inspection  they  are  recog- 
nized by  their  yellowish  coloi-,  usually  small  size,  and  their  dissemina- 
tion over  a  considerable  area  of  the  mucous  membrane.  In  the  more 
fully  developed  ulcers  the  caseous  degeneration  of  the  inflammatory 
products  may  be  observed. 

Mr.  Allingham  describes  a  rare  form  of  ulcer  which  he  has  occasion- 
ally observed  in  the  rectum,  and  which  he  has  named  lupoid^  or  rodent 
ulcer,  of  this  organ.  Its  usual  location  is  near  the  anus.  It  tends  to 
spread  widely,  the  floor  of  the  ulcer  is  red  and  dry,  the  margins  irregular 
and  precipitous.     It  is  very  probably  tubercular  in  character. 

Chancroidal  ulcer  of  the  rectum  may  be  recognized  by  the  precipitous 
margins  of  these  sores,  and  by  the  rapidity  with  which  they  spread. 
In  patients  affected  with  phagedenic  iilcers  of  the  genital  organs,  the 
inoculation  may  occur  by  direct  contact  of  the  secretion  of  the  venereal 
sore,  or  the  virus  may  be  conveyed  through  the  medium  of  the  nails  in 
the  act  of  scratching.  Under  such  conditions  the  sore  usually  first  ap- 
pears upon  the  mucous  membrane  of  the  margins  of  the  anus,  and  ex- 
tends later  into  the  rectum.     The  diagnosis  must  be  based  upon  the 


ULCER  OF  THE   ANUS  AND   RECTUM.  601 

peculiar  appearance  of  tlie  ulcer,  together  with  the  probabilities  of  in- 
fection from  a  contiguous  venereal  ulcer. 

The  hard  syphilitic  or  true  chancre  is  rarely  observed  in  this  region, 
and,  when  met  with,  is  usually  confined  to  the  anal  margin.  It  possesses 
here  the  same  well-recognized  features  of  the  specific  ulcer  of  the  genital 
organs,  from  which  source  the  virus  is  conveyed  usually  by  the  nails, 
and  occasionally  by  immediate  contagion. 

Ulcers  of  the  rectum  resulting  from  the  breaking  down  of  the  gumma- 
tous deposits  of  tertiary  syphilis  are  chiefly  seen  Just  along  the  upper 
margin  of  the  sphincter  muscle.  From  this  point  they  extend  upward, 
and  may  involve  the  entire  rectum  and  invade  the  colon.  These  ulcers 
are  usually  multiple,  varying  in  size  from  a  small  point  to  a  half-inch 
or  more  in  diameter,  and  in  depth  may  involve  only  the  mucous  mem- 
brane, or  the  muscular  and  connective-tissue  stroma  may  be  destroyed, 
and  in  some  instances  perforation  may  occur.  The  process  of  destruc- 
tion is  greater  in  the  older  ulcers,  and  the  various  stages  may  be  observed 
by  examining  the  bowel  from  below  upward.  The  appearance  of  the 
ulcers  as  above  described,  together  with  the  history  of  syphilis,  will  en- 
able the  observer  to  arrive  at  a  correct  diagnosis.  Traumatic  ulcers,  and 
those  resulting  from  the  breaking  down  of  heemorrhoidal  tumors,  will 
be  recognized  by  the  appearance  of  the  sore  and  the  history  of  an  acci- 
dent or  haemorrhoids. 

As  far  as  a  cure  of  the  ulcer  is  concerned,  a  favorable  prognosis 
may  be  made  in  all  ulcers  of  the  rectum  except  the  tubercidar.  These 
may  be  relieved  by  treatment,  but,  being  expressions  of  an  incurable 
dyscrasia,  permanent  relief  can  not  be  expected.  A  more  remote, 
as  well  as  greater  evil  which  often  results  from  ulcer,  is  stricture  of 
the  rectum,  and  the  danger  of  stricture  is  usually  proportionate  to 
the  extent  of  the  destructive  process.  Phagedenic  chancroidal  ulcer, 
and  the  ulcers  of  gumma  and  dysentery,  are  especially  prone  to  induce 
stricture. 

Treatment.  — The  common  indication  in  the  treatment  of  all  forms  of 
ulcer  of  the  rectum  is  to  keep  the  bowel  in  as  complete  repose  as  possi- 
ble. Every  effort  should  be  made  to  keep  it  clear  of  fecal  matter.  This 
may  be  accomplished  by  the  repeated  employment  of  enemata,  and  by 
the  administration  of  proper  articles  of  diet,  all  of  which  should  be 
capable  of  absorption  in  the  stomach  and  small  intestines.  Milk,  beef- 
tea,  meat-juice,  soft-boiled  eggs,  wine-jelly,  rice,  corn-meal  mush,  etc., 
will  afford  variety  and  sustain  the  patient's  nutrition. 

In  irrigation  of  the  diseased  surface,  warm  or  cold  water  may  be  used 
at  the  temperature  which  is  most  agreeable  to  the  patient.  The  best 
apparatus  for  this  purpose  is  the  fountain- syringe.  The  smallest  glass 
nozzle,  thoroughly  warmed  and  oiled,  should  be  employed,  and  from  one 
to  two  pints  of  fluid  may  be  introduced  at  one  injection.  A  larger  quan- 
tity may  be  employed  when  the  colon  is  involved.  If  the  patient  is 
placed  upon  the  left  side,  with  the  buttocks  elevated,  a  greater  degree 
of  tolerance  will  be  obtained  in  the  rectum.  The  fluid  should  be  re- 
tained for  a  few  minutes,  if  possible. 


602  A  TEXT-BOOK   ON   SURGERY. 

When  the  ulcer  encroaches  upon  the  sphincter  muscle,  causing  pain- 
ful tenesmus,  the  hypodermic  use  of  morphia  or  opium  suppositories 
may  be  required  to  relieve  the  spasm.  In  obstinate  cases  divulsion  or 
division  of  the  sphincter  may  be  done  as  a  last  resort. 

In  the  treatment  of  the  ulcers  which  result  from  dysentery,  catarrh 
of  the  rectum,  an  injury,  or  breaking  down  of  haemorrhoids,  the  plan 
just  given  should  be  adopted.  It  is  often  advisable  to  add  from  grs.  v-x 
of  nitrate  of  silver  to  the  pint  of  water  thrown  in,  and,  if  the  ulcer  can 
be  reached,  recovery  will  be  hastened  by  the  local  use  of  the  lunar  caus- 
tic. An  excellent  remedy  for  the  alleviation  of  pain  and  the  relief  of 
tenesmus  is  a  supi^ositorj  composed  of  gr.  ij  each  of  iodoform  and  co- 
caine hydrochlorate,  introduced  from  three  to  five  times  in  twenty-fonr 
hours.  As  already  stated,  in  obstinate  and  extreme  cases,  lumbar  coloto- 
my  may  be  necessitated , 

Chancroidal  ulcer  of  the  rectum  requii-es  the  most  energetic  treat- 
ment. Ether  should  be  administered,  the  sphincter  divulsed,  the  ulcer 
exposed  by  the  sjieculum,  its  surface  scraped  with  the  curette,  and  a 
thorough  cauterization  effected  with  nitric  acid.  The  cocaine  and  iodo- 
fonn  suppositories  should  be  employed  in  the  after-treatment. 

True  syphilitic  chancre  of  the  rectum  rarely  demands  local  treat- 
ment. It  yields  readily  to  the  constitutional  remedies  employed  in 
syphilis. 

The  specific  ulcer  of  the  later  stages  of  syphilis  requires  the  consti- 
tutional treatment  recommended  for  the  late  manifestations  of  this  dis- 
ease, and  locally,  irrigation  and  the  cocaine  and  iodoform  suppositories. 

Tubercular  ulcers  should  be  treated  chiefly  by  the  administration  of 
cod-liver  oil  emulsion,  the  iron  tonics,  the  hypophosphites  of  lime  and 
soda,  and  carefully  selected  diet.  Irrigation  with  warm  water  will  be 
found  useful.  When  pain  and  tenesmus  exist,  relief  may  be  obtained 
by  the  means  already  given. 

In  rodent,  or  lupoid  ulcer,  the  Paquelin  cautery-knife  should  be  em- 
ployed, and  a  thorough  excision  of  the  diseased  surface  effected. 

Stricture  of  the  Rectum. — Stricture  of  the  rectum  may  be  congenital 
or  acquired.  Partial  and  complete  congenital  occlusion  of  this  organ  has 
already  been  considered.  Acquired  stricture  is  usually  the  result  of  an 
inflammatory  process  in  the  walls  of  the  rectum,  and  at  times  in  the  tis- 
sues which  surround  this  organ  (Fig.  559).  IS^ew  formations  (cancer, 
etc.)  may  also  cause  a  partial  or  complete  occlusion  of  the  rectum,  not 
only  by  reason  of  the  bulk  of  the  cells  proper  of  the  neoplasm,  but  on 
account  of  the  inflammatory  process  which  it  causes  in  the  connective- 
tissue  elements  of  the  bowel. 

The  lumen  of  this  portion  of  the  intestine  may  be  partially  or  com- 
pletely occluded  by  pressure  of  a  tumor  not  connected  with  the  bowel, 
or  by  the  presence  of  some  displaced  organ,  as  the  uteriis,  bladder,  etc. 
Lastly,  spasmodic  stricture  may  occur  from  contraction  of  the  circular 
muscular  fibers  of  the  rectum. 

As  stated  on  a  previous  page,  organic  stricture  frequently  follows 
ulcer  of  the  rectum,  and  is  especially  apt  to  occur  in  the  process  of  cica- 


STRICTURE   OF  THE  RECTUM. 


603 


trization  after  dysenteric  ulcers  and  those  of  the  tertiary  stage  of  syphi- 
lis.    The  accidents  of  partiu'ition  not  infi-equently  tend  to  stricture,  and 
this  may  account  for  the  greater  preralence 
of  this  lesion  in  females  than  in  males. 

Stricture  of  the  rectum  may  be  narrow 
or  linear,  or  long  and  tortuous.  The  usual 
location  is  about  two  inches  above  the  mar- 
gin of  the  anus,  although  any  part  of  the 
organ  may  be  involved.  The  earlier  symp- 
toms of  this  lesion  are  interference  with  the 
act  of  defecation,  pain  with  the  passage  of 
fseces,  and  the  presence  of  blood  or  mucus 
in  the  discharges.  In  some  instances  the 
faeces  are  tape-like,  or  are  abnormally 
shaped,  although  this  symptom  may  not  be 
present  when  the  stricture  is  high  up,  since 
the  fecal  matter,  after  it  passes  through  the 
constriction,  may  assume  the  shape  of  the 
bowel  below.  If  the  constriction  is  situ- 
ated within  the  first  four  inches  of  the 
bowel,  its  presence  and  caliber  may  be  de- 
termined by  digital  exploration.  When 
with  difficulty  reached  by  the  finger,  the 
patient  should  be  directed  to  strain  as  if 
at  stool,  in  order  to  force  the  obstruction 
nearer  the  anus.  Beyond  this  limit  the 
bulbous  bougies  must  be  relied  upon.  These  instruments  are  of  all  sizes, 
each  consisting  of  an  oval  bulb  of  hard  rubber,  attached  to  the  end  of 
a  flexible  whalebone  staff.  In  introducing  them  the  patient  should  rest 
upon  the  back  while  the 
bougie,  warmed  and  oiled, 
is  guided  up  the  bowel, 
upon  the  index-finger  of 
the  left  hand,  which  is 
carried  its  full  length  into 
the  rectum  (Fig.  560).  If 
resistance  is  met  with, 
only  careful  and  gentls 
pressure  should  be  ex- 
ercised, for  undue  vio- 
lence may  drive  the  bulb 
through  the  wall  of  the 
gut.  The  inferior  limit 
of  the  stricture  is  indi- 
cated by  the  first  obstruc- 
tion encountered.  If  the  bulb  can  be  carried  through  the  constriction, 
the  resistance  ceases,  but  is  again  experienced  when,  upon  withdra-R-ing 
it,  the  shoulder  of  the  instrument  catches  at  the  upper  limit  of  the 


Fig.  559. — Stricture  of  the  rectum  from 
connective-tissue  new-formation  in 
the  submucous  layer.   (Alter  Bushe.) 


-Method  of  introducing:  the  hulbous  bougie  in  explora- 
tion of  the  rectuih.     (After  Bushe.) 


604 


A  TEXT-BOOK   ON   SURGERY. 


obstraction.  Tlie  lower  border  of  the  stricture  is  again  indicated  when 
all  resistance  ceases  in  withdrawing  the  bulb. 

Treatment. — The  surgical  treatment  of  stricture  of  the  rectum  may 
comprise  dilatation  or  division  of  the  cicatricial  tissue  or  colotomy. 

The  character  of  the  obstruction  and  its  location  will  determine  the 
means  to  be  employed.  AVhen  the  stricture  is  linear,  and  is  located 
near  the  anus,  relief  may  be  obtained  by  dilatation.  For  this  purpose 
the  finger  should  be  employed,  and  the  operation  repeated  at  necessary 
intervals  until  a  sufiicient  opening  is  secured.  If  the  cicatricial  tissue 
is  dense,  and  does  not  yield  in  the  effort  at  dilatation,  it  should  be  in- 
cised to  a  slight  depth  at  four  or  five  points  of  its  circumference,  and 
the  finger  again  introduced.  The  incisions  may  be  made  with  a  probe- 
pointed  bistoury,  carried  along  the  finger  as  a  guide,  or  the  anus  and 
bowel  may  be  stretched  with  the  Sims  rectal  speculum  iip  to  the  point 
of  obstruction,  and  the  knife  introduced  withoiit  a  guide.  If  this  pro- 
cedure is  not  successful,  the  only  alternative  is  posterior  linear  rectoto- 
my.  In  performing  this  operation  the  patient  is  placed  upon  the  back, 
with  the  anus  at  the  edge  of  the  table,  and  the  legs  drawn  up  and  sepa- 
rated. The  parts  below  the  obstruction  are  dilated  with  the  speculum. 
A  long,  curved,  sharp-pointed  bistoury  is  carried  through  the  stricture, 
keeping  the  cutting  edge  toward  the  posterior  median  line  of  the  gut. 
As  soon  as  the  point  is  beyond  the  obstruction,  hut  not  more  than  four 
inches  from  the  anus,  it  is  carried  through  the  wall  of  the  bowel,  which, 
with  the  stricture,  is  completely  divided  out  through  the  anus.  If  the 
first  incision  does  not  permit  the  introduction  of  the  first  two  fingers 
side  by  side,  it  should  be  made  deeper.  Haemorrhage  is  readily  stopped 
by  packing  the  wound  and  bowel  with  gauze,  taking  the  precaution  to 
insert  a  stiff  rubber  tube  in  the  middle  of  the  dressing  to  allow  the 
escape  of  gas  from  the  intestine.  If  any  important  vessel  is  divided, 
it  may  be  secured  with  the  forceps  or  by  transfixion  with  a  tenaculum. 
The  dressing  is  allowed  to  remain  in  place  for  four  or  five  days,  and 
is  not  replaced  after  the  bowels  are  moved  unless  bleeding  should 
occur.  Continence  of  faeces  is  restored  after  from  three  to  six  weeks. 
No  matter  how  thoroughly  divided,    the   tendency  is  to  recurrence, 


G.  T/EMANN  &C0  . 

Fig.  561. — Soft-rubber  rectal  bougies  (twelve  sizes). 


which  necessitates  interrupted  dilatation  at  intervals  of  from  three 
to  six  weeks  during  the  life  of  the  patient.  It  is  usually  not  neces- 
sary to  practice  dilatation  within  the  first  six  or  eight  weeks  after  the 
operation. 


NEOPLASMS   OF  THE   RECTUM  AXD  AXUS.  605 

Wlien  the  stricture  is  situated  more  tlian  four  inches  above  tlie  antis, 
rectotomy  is  not  permissible  on  account  of  the  proximity  of  the  large 
hgemorrhoidal  vessels,  the  peritonaeum,  and  pelvic  fascia.  Dilatation 
with  the  soft-rubber  bougies  (Fig.  561)  may  be  tried,  and,  if  this  faUs,  a 
rectotomy  may  be  done  as  high  as  the  limit  already  given,  wMch  will 
allow  the  introduction  of  the  hand  to  this  point  and  the  iinger  into  the 
stricture.  This  may  now  be  nicked  with  the  bistoury,  as  above  de- 
scribed, and  digital  or  instrumental  dilatation  effected.  Rectal  bougies 
before  being  used  should  be  made  thoroughly  flexible  by  immersion  in 
warm  water.  In  their  employment  only  a  mild  degree  of  force  should 
be  exercised,  for  fear  of  perforating  the  wall  of  the  intestine. 

AVhen  all  other  measures  fail,  colotomy  is  the  last  resort. 


Neoplasms  of  the  EECxrM  axd  Aktjs. 

Carcinovia. — Of  the  malignant  new  formations  which  are  found  in 
this  organ,  epithelioma  is  the  most  common,  scirrhus  and  encephaloid 
cancer  being  next  in  order  of  frequency.  The  latter  is  comparatively 
rare.  Cancer  of  the  rectum  occurs  about  equally  in  the  sexes,  and 
almost  always  in  the  middle-aged  and  old,  although  in  exceptional  in- 
stances it  has  been  observed  before  the  age  of  twenty -five. 

Epithelioma  begins  in  the  mucous  membrane,  sciiThus  and  encepha- 
loid carcinoma  in  the  submucous  tissues. 

The  former  is  slower  in  development  and  less  apt  to  recur  after  re- 
moval. The  most  common  location  of  cancer  of  the  lower  bowel  is  at 
the  upper  margta  of  the  sphincter  muscle. 

The  prognosis  is  gTave,  the  duration  of  life  varying  from  one  to  two 
or  three  years,  and  in  exceptional  cases  longer.  Usually  the  earliest 
symptom  of  cancer  of  the  rectum  is  pain  ■«'ith  the  act  of  defecation.  If 
the  disease  is  located  at  the  margin  of  the  anus,  it  can  be  recognized 
before  there  is  any  interference  with  the  discharge  of  fecal  matter. 
Later,  haemorrhage  is  of  frequent  occurrence,  although,  as  a  rule,  it  is 
not  profuse  in  character.  After  an  evacuation  of  the  contents  of  the 
bowel,  the  pain,  though  less  intense,  remains  for  some  time.  A  sense 
of  fuUness  or  "  bearing  down"  is  a  marked  feature  of  this  disease  in  the 
majority  of  cases. 

Diagnosis. — If  operative  interference  is  to  be  undertaken,  it  is  im- 
portant that  an  early  diagnosis  be  made.  Epithelioma,  as  has  been 
said,  begins  in  the  mucous  membrane,  the  cells  of  the  new  formation 
break  down  early,  the  ulcer  being  present  in  some  instances  before 
there  is  marked  induration.  On  the  other  hand,  induration  and  thick- 
ening are  observed  early  in  the  history  of  scin-hus  and  encephaloid. 

ISTon-malignant  stricture  of  the  rectum  is  always  preceded  by  a  his- 
tory of  chronic  inflammation.  To  the  touch,  the  cicatricial  character  of 
the  tissue  may  be  recognized  by  its  firmness  and  sharp  borders.  It  is 
not  nodular,  like  cancer,  nor  is  there  a  deep  and  wide  infiltration  of  the 
surrounding  tissues  in  simple  stricture,  which  condition  is  common  to 


606  A  TEXT-BOOK   ON   SURGERY. 

scirrlius  and  encephaloid,  and  the  later  stages  of  epithelioma.  In  doubt- 
ful cases  it  will  be  advisable  to  remove  a  portion  of  the  mass  for  micro- 
scopical examination. 

The  treatment  of  cancer  of  the  rectum  may  be  palliative  or  radical. 
The  former  looks  to  the  prolongation  of  life  and  the  alleviation  of  pain 
by  the  employment  of  careful  dietetic  and  medicinal  measures.  The 
regular  daily  introduction  of  warm  water  will  prevent  the  lodgment  of 
fecal  matter  and  secure  the  greatest  possible  immunity  from  irritation. 
The  iodoform  and  cocaine  suppositories  will  be  found  useful  in  alleviat- 
ing pain,  and  morphia  may  be  employed  if  all  other  measures  fail.  As 
the  disease  progresses  it  will  be  found  necessary  to  practice  dilatation 
of  the  stricture  at  intervals  which  should  be  as  far  removed  as  possible, 
or  partial  or  complete  division  may  be  required. 

The  radical  treatment  consists  in  the  free  excision  of  the  neoj)lasm. 
The  death-rate  after  this  operation  is  exceedingly  heavy,  and,  when  the 
dissection  is  extensive  and  recovery  follows,  the  condition  of  fecal  in- 
continence is  deplorable.  Moreover,  the  tendency  to  recurrence  is  so 
great  that  this  knowledge  should  deter  the  surgeon  from  undertaking 
the  operation  in  other  than  the  mildest  cases.  When  the  disease  extends 
higher  than  three  inches  from  the  anus,  it  is  of  doubtful  propriety,  and 
in  scirrhus  and  encephaloid  cancer,  on  account  of  the  rapid  and  wide 
infiltration  which  occurs  with,  these  neoplasms,  the  operation  does  not 
offer  a  prospect  of  relief  sufficient  to  justify  the  danger  which  is  in- 
curred. 

Excision  is  justifiable  and  should  be  done  in  all  cases  of  epithelioma 
situated  within  three  inches  of  the  anus  which  have  been  discovered 
before  infiltration  is  deep,  or  before  metastasis  has  occurred.  When 
undertaken,  the  dissection  should  be  carried  on  well  away  from  the  dis- 
ease, in  the  perfectly  healthy  tissues.  It  is  performed  as  follows  :  The 
patient  should  be  prepared  for  the  operation  by  being  placed  upon  liquid 
diet  for  one  week,  and  the  lower  bowel  should  be  thoroughly  cleansed 
by  repeated  injections  of  tepid  water.  A  good  light  should  be  secured, 
the  patient  placed  in  the  lithotomy  position,  and  the  parts  in  the  field 
of  operation  shaved.  The  rectum  should  be  well  packed  with  sponges 
to  prevent  the  escape  of  fluids  or  other  matter  from  the  bowel  into  the 
wound.  The  niimber  of  sponges  should  be  noted,  so  that  the  operator 
may  be  sure  that  none  are  left  in  after  the  excision  is  completed.  In 
order  to  secure  as  great  a  degree  of  continence  after  the  operation  as 
possible,  all  or  a  portion  of  the  external  sphincter  should  be  preserved. 
However,  if  the  disease  involves  this  muscle,  it  should  be  removed. 

An  elliptical  incision  is  first  made  around  the  anus  along  the  junction 
of  the  skin  and  mucous  membrane  (or  wider  than  this  if  the  extent  of 
the  disease  demands  it),  and  the  dissection  carried  up  through  the  inner 
fibers  of  the  external  sphincter,  the  posterior  insertion  of  which  should 
be  split  as  far  back  as  the  tip  of  the  coccyx,  in  order  to  give  more  room. 
When  the  disease  is  approached,  the  dissection  should  be  kept  well  out 
from  the  gut  in  the  healthy  tissues.  Within  the  first  inch  of  the  dissec- 
tion the  bleeding  points  may  be  readily  secured  by  the  forceps,  but. 


POLYPI   OF  THE   RECTUM.  607 

beyond  this  limit,  the  operation  vnll  be  ranch  more  rapidly  and  satis- 
factorily performed  if  the  tissues  are  divided  throughout  between  two 
forceps  and  catgut  ligatures  applied  at  once.  It  is  best  not  to  encroach 
upon  the  vagina  or  urethi-a  and  bladder  any  more  than  is  essential  to  the 
thorough  removal  of  the  disease,  but  to  utilize  the  ischio-rectal  fossa  in 
securing  room  for  the  deeper  dissection.  As  soon  as  the  lower  end  of 
the  rectum  is  freed,  the  wound  should  be  packed  temporarily  with  gauze, 
the  sponges  removed,  and  the  bowel  closed  by  tying  a  strong  silk  liga- 
ture around  it.  It  is  essential  to  the  complete  success  of  the  operation 
that  the  gut  be  dissected  loose,  not  only  an  inch  above  the  upper  limit  of 
the  disease  where  it  is  ultimately  to  be  divided,  but  to  a  sufficient  extent 
beyond  this  point  to  permit  its  being  drawn  down  until  it  can  be  stitched 
to  the  margin  of  the  incision  in  the  integument  around  the  anus.  When 
this  is  accomplished  the  gut  should  be  drawn  down,  a  strong  silk  suture 
carried  through  the  integument  on  each  side  and  into  the  wall  of  the 
intestine,  just  above  the  line  of  section,  and  secured.  The  gut  should 
now  be  cut  ofE  with  the  scissors,  and  other  sutures  inserted.  A  drain- 
age-tube should  be  placed  in  the  ischio-rectal  fossa,  the  end  projecting 
on  one  side  of  the  anus.  A  sublimate  dressing  should  be  applied,  leaving 
a  tube  in  the  bowel  for  the  escape  of  gas.  In  the  after-treatment  opium 
should  be  administered  to  prevent  a  movement  of  the  bowels  for  a  week 
or  ten  days. 

Polypus. — Three  distinct  forms  of  polypi  are  found  in  the  rectum, 
namely — the  villous,  mucous,  and  fibrous. 

The  first  of  these  is  the  more  important,  for,  whUe  essentially  benign 
in  the  earlier  stages  of  its  development,  it  not  infrequently,  as  a  result 
of  the  irritation  to  which  it  is  subjected,  becomes  malignant.  It  is  com- 
posed of  new-formed  villi,  which  resemble  the  normal  villi  of  the  rectum. 
They  are  very  vascular,  and  differ  from  the  mucous  or  fibrous  polypus 
not  only  in  their  minute  structure,  but  in  gross  appearances  and  the 
character  of  their  attachment  to  the  mucous  membrane.  While  these 
latter  are  pedunculated,  often  hanging  by  a  narrow  stem,  the  villous 
growth  has  a  broad  attachment  frequently  as  thick  as  the  tumor  is  long. 

The  mucous  or  soft,  and  the  fibrous  or  hard,  polypus  of  the  rectum 
does  not  differ  in  any  essential  particular  from  that  already  described 
in  affections  of  the  nasal  cavities.  In  some  instances  the  deeper  portions 
of  the  tumor  undergo  cystic  degeneration,  forming  the  so-caUed  cystic 
polypus. 

Polypi  of  the  rectum  may  occur  at  any  period  of  life,  being  compara- 
tively frequent  in  childhood.  The  most  common  location  of  these  tumors 
is  on  the  posterior  wall  of  the  bowel,  just  above  the  internal  sphincter. 
The  pedunculated  variety  in  some  instances  protrude  through  the  anus, 
causing  violent  tenesmus.  AVhen  not  removed  these  neoplasms  may 
break  down,  causing  ulcer  or  fissure  of  the  bowel,  severe  htemorrhage, 
or  by  their  weight  cause  prolapse  of  the  mucous  membrane. 

The  diagnosis  is  readily  made  by  inspection  or  digital  exploration, 
after  the  rectum  is  thoroughly  cleansed-  by  an  enema.  The  treatment 
consists  in  removal  of  the  tumor  by  the  forceps,  scissors,  or  ligature. 


608  A  TEXT-BOOK   ON   SURGERY. 

Villous  polyiJTis  may  be  safely  removed  by  transfixing  its  base  with  a 
double  silk  ligature,  tying  these,  and  allowing  the  mass  to  slough  away ; 
or,  with  the  sphincter  fully  dilated,  the  tumor  may  be  removed  by  the 
curette.  The  haemorrhage  is  not  severe,  and  may  be  arrested  by  packing 
with  gauze. 

The  pedunculated  tumors  may  be  twisted  off  with  the  forceps  or 
clipped  closely  with  the  curved  scissors.  The  stump  should  be  touched 
with  lunar  caustic  or  burned  with  nitric  acid  or  the  cautery. 

Neuralgia. — Pain,  neuralgic  in  character,  is  occasionally  felt  in  the 
rectum  or  about  the  anus.  In  some  instances  it  is  caused  by  displace- 
ment of  the  coccyx,  the  bone  in  the  abnormal  position  pressing  upon  the 
fifth  sacral  or  coccygeal  nerve,  or  directly  against  the  wall  of  the  bowel. 
The  diagnosis  is  readily  made  out  by  direct  examination.  The  only 
means  of  cure  is  by  removal  of  the  displaced  bone. 

The  operation  is  performed  as  follows :  The  patient  is  placed  upon 
the  side,  an  incision  is  made  in  the  median  line,  from  the  tip  of  the  coc- 
cyx to  about  one  inch  above  the  sacro-coccygeal  articulation.  The  tissues 
are  first  lifted  directly  from  the  dorsal  aspect  of  the  bone,  and  then  the 
anterior  surface  is  exposed  by  beginning  at  the  tip  and  keeping  close 
to  the  smooth  face  of  the  coccyx.  There  is  no  danger  of  wounding  the 
bowel  if  this  precaution  is  taken.  When  the  dissection  is  completed, 
the  bone  should  be  divided  at  the  sacro-coccygeal  junction  with  the  cut- 
ting-forceps or  chisel. 

Idiopathic  neuralgia  of  the  rectum  and  anus  may  occur  as  in  other 
portions  of  the  body.  Spasm  of  the  sphincter  is  occasionally  due  to  this 
cause. 

Prolapsus  Recti. — Protrusion  of  the  rectum  may  be  complete  or  in- 
complete. In  the  incomplete  variety  the  lining  membrane  of  the  bowel 
is  alone  protruded.  The  everted  portion  may  include  a  narrow  ring  of 
the  mucous  membrane  near  the  anus,  or  it  may  measure  an  inch  or  more 
in  width.  In  the  complete  prolapsus  more  or  less  of  the  entire  thick- 
ness of  the  wall  of  the  rectum  is  dragged  downward  and  everted.  The 
process  commences  usually  near  the  anus,  and  in  the  complete  form  the 
fascia  which  attaches  the  rectum  to  the  promontory  of  the  sacrum  is 
elongated,  and  the  peritonaeum  dragged  down  toward  the  anal  aperture. 
In  the  pocket  thus  formed  a  loop  of  intestine  may  descend  and  become 
strangulated. 

Prolapsus  recti  may  occur  at  any  period  of  life,  although  usually  met 
with  in  children.  In  a  varying  degree  it  exists  as  a  complication  in  all 
cases  of  chronic  haemorrhoids.  It  is  chiefly  caused  by  frequent  and  pro- 
longed straining  at  stool.  A  predisposing  cause  in  adults  is  habitual 
constipation,  with  the  over-distention  of  the  bowel  which  is  the  result 
of  this  condition.  In  children,  it  is  thought  that  the  peculiar  shape  of 
the  sacrum,  the  curve  of  which  is  much  less  pronounced  than  in  adults, 
renders  this  class  of  patients  more  liable  to  prolapsus.  It  is  probable 
that  indiscretions  in  diet,  the  lack  of  resti-aint,  and  the  low,  squatting 
posture  too  often  permitted  in  children  in  the  act  of  defecation,  are  more 
responsible  for  this  accident  than  the  straight  position  of  the  bowel. 


PROLAPSUS   OF  THE   RECTUM  AND   ANUS.  609 

Diseases  of  the  bladder  and  prostate,  uterus  and  ovaries,  pregnancy, 
or  the  presence  of  a  tumor,  are  also  to  be  considered  as  exciting  causes 
of  this  lesion.  Finally,  the  weak  and  infirm  are  more  liable  to  be 
affected  than  the  robust. 

When  prolapsus  occurs  it  is  accompanied  with  a  sense  of  distention, 
heaviness,  and  dragging  down,  which  causes  great  pain  and  anxiety  to 
the  patient.  In  recent  cases  in  which  there  is  only  an  eversion  of  the 
mucous  membrane,  this  will  be  seen  projecting  beyond  the  limit  of  the 
anus  on  one  or  both  sides,  or  in  severer  cases  including  its  entire  cir- 
cumference. The  prolapsed  fold  or  ring  is  of  a  reddish-purple  color, 
varying  with  the  degree  of  strangulation,  and  is  broken  at  intervals  by 
furrows  or  depressions  which,  in  the  main,  seem  to  radiate  from  the 
center  of  the  protrusion.  When  complicated  with  haemorrhoids,  these 
will  be  easily  recognized  by  their  shape  and  color,  giving  a  swollen  and 
nodulated  appearance,  which  could  not  exist  in  simple  eversion.  In 
differentiating  partial  from  complete  prolapsus,  the  chief  points  are  the 
thinness  of  the  prolapsed  ring  in  the  partial  form,  and  the  radiating 
direction  of  the  farrows.  In  complete  prolapse  the  mass  is  markedly 
thicker,  more  strangulated,  and  the  folds  of  mucous  membrane  are  more 
nearly  circular  in  arrangement. 

Treatment. — In  acute  prolapsus  the  immediate  indication  is  to  relieve 
the  strangulation  and  restore  the  prolapsed  portion  to  its  normal  posi- 
tion. The  removal  of  the  cause  or  causes  of  the  accident  is  next  in 
importance.  The  first  indication  is  met  by  placing  the  patient  upon 
the  left  side,  with  the  pelvis  well  elevated,  the  shoulders  and  head  de- 
pressed, or  in  the  knee-shoulder  position,  in  either  of  which  the  return 
of  the  bowel  is  aided  by  gravity.  The  fingers  of  the  operator  and  the 
protruded  mass  should  now  be  well  lubricated,  and  steady  and  gentle 
pressure  exercised  upon  the  tumor  in  the  direction  of  the  normal  posi- 
tion of  the  bowel.  In  almost  all  cases  this  practice  will  succeed.  When, 
on  account  of  spasm  of  the  sphincter,  the  strangulation  is  so  great  that 
gangrene  is  threatened  and  reduction  impossible,  an  anaesthetic  should 
be  administered  and  forcible  dilatation  effected  by  the  thumbs  of  the 
operator,  after  which  the  mass  will  readily  return  within  the  anus.  Once 
reduced,  the  greatest  pains  must  be  observed  to  prevent  the  repetition 
of  the  accident.  Fecal  accumulation  and  straining  should  be  prevented 
by  the  injection  of  cold  water  when  there  is  a  need  or  desire  for  an 
evacuation,  and  by  the  use  of  the  bed-pan.  In  children  it  is  essential 
that  they  should  not  be  allowed  to  squat  upon  a  low  vessel,  or  place 
themselves  in  a  constrained  position  at  stool.  The  position  assumed 
should  be  one  where  gravitation  will  not  carry  the  intestines  toward  the 
anus.  Lying  upon  the  side,  with  the  buttocks  slightly  projecting  over 
the  edge  of  the  bed  or  table,  or  defecating  in  the  knee-elbow  position, 
should  be  insisted  upon.  Any  condition  which  contributes  to  the  cause 
of  prolapse  must  be  removed  or  palliated.  When,  despite  all  conserva- 
tive methods,  the  prolapse  becomes  chronic,  growing  jjrogressively  worse, 
operative  interference  becomes  imperative.  The  preparation  of  the  pa- 
tient is  the  same  as  for  other  operations  about  the  rectum.  After  the 
39 


610  A  TEXT-BOOK   ON   SURGERY. 

narcosis  is  complete,  tlie  patient  is  placed  in  tlie  lithotomy  position,  with 
the  pelvis  elevated  to  such  an  extent  that  the  intestines  will  gravitate 
toward  the  diaphragm,  the  mass  returned,  and  a  large  sponge  introduced 
well  up  into  the  bowel.  The  sphincter  ani  and  rectum  should  now  be 
widely  dilated  with  the  speculum  until  the  walls  of  the  bowel  are  brought 
clearly  into  view.  The  Paquelin  cautery-knife,  heated  to  a  light-red 
color,  is  carried  into  the  bowel  as  high  as  the  limit  of  the  prolapsed 
portion,  and  drawn  straight  down  the  wall  of  the  gut  to  the  margins  of 
the  anus,  burning  its  way  through  the  mucous  membrane.  The  depth 
of  the  furrow  must  be  determined  by  the  extent  of  the  prolapse.  If 
the  entire  thickness  of  the  rectal  wall  is  involved,  as  in  complete  pro- 
lapsus, the  wound  should  extend  well  into  the  muscular  layer.  In  par- 
tial prolapse  it  will  suffice  to  go  down  to  the  muscle.  From  four  to  six 
incisions  should  be  made  at  equal  distances  from  each  other.  Partial 
divulsion  of  the  sphincter  should  be  made  before  or  after  the  operation, 
in  order  to  prevent  spasm  and  to  secure  rest.  A  complete  recovery  will 
follow  in  the  large  majority  of  cases.  If  the  Paquelin  cautery  can  not 
be  obtained,  strong  iron  wire,  or  rod-iron,  may  be  used  by  heating  in 
the  ordinary  furnace.  The  after-treatment  is  to  keep  the  jiatient  quiet 
with  mild  opium  narcosis,  and  after  live  or  six  days  to  move  the  bowels 
with  a  cold-water  enema,  keeping  the  patient  in  the  recumbent  posture. 
The  cure  is  effected  by  the  formation  of  inflammatory  adhesions  between 
the  mucous  membrane  and  muscle,  and  between  the  outer  wall  of  the 
rectum  and  the  peri-rectal  connective  tissues  and  fasciae.  The  older 
operation  of  excising  a  V-shaped  piece  of  the  mucous  membrane  and 
afterward  uniting  the  edges  by  sutures,  is  bloody  and  troublesome,  and 
not  to  be  compared  to  the  procedure  above  given. 

In  chronic  prolapsus,  the  operation  is  the  same,  provided  that  reduc- 
tion can  be  effected.  The  incisions  with  the  cautery-knife  must  extend 
deeply,  as  above  indicated.  When  reduction  is  impossible,  owing  to  the 
inflammatory  thickening  of  the  protruded  mass,  there  is  no  alternative  but 
in  excision.  In  this  operation  the  integrity  of  the  sphincter  must  not  be 
impaired.  Preferably,  the  mass  should  be  cut  off  with  a  delicate  cautery- 
knife,  keeping  just  outside  the  sphincter,  which  is  usually  slightly  drawn 
out  with  the  gut.  The  line  of  incision  should  be  circixlar,  and,  by  allow- 
ing the  knife  to  burn  its  way  slowly,  all  danger  of  hsemorrhage  is  avoid- 
ed.    The  after-treatment  is  the  same  as  in  the  preceding  operation. 

When  the  cautery-knife  is  not  at  hand,  a  rim  of  the  everted  mucous 
membrane,  and  a  corresponding  rim  of  the  integument  which  has  been 
drawn  down  with  the  prolapse,  may  be  cut  off  with  the  scissors,  and 
forceps  inverted  and  sutured  with  catgut,  as  after  Whitehead's  operation 
for  hsemorrhoids,  given  on  another  page. 

Another  method  is  to  insert  a  series  of  ligatures  of  strong  silk  around 
the  prolapsed  mass  at  the  level  of  the  anus.  These  extend  through  both 
thicknesses  of  the  gut.  When  tied  tightly,  strangulation  of  the  portion 
beyond  the  ligatures  occurs,  and  this  should  be  cut  off  to  within  a  quar- 
ter of  an  inch  of  the  ligatures. 


i 


HEMORRHOIDS.  611 


H^ilOREHOIDS. 


Hsemorrhoids,  or  "piles,"  are  vascular  tumors  or  varicosities  forroed 
beneath  the  mucous  membrane  of  the  rectum  and  anus.  They  are 
divided  anatomically  into  external  and  internal  haemorrhoids.  Internal 
hsemorrhoids  are  again  divided  into  venous,  arterio-venous,  and  capil- 
lary haemorrhoids. 

The  veins  which  are  involved  in  haemorrhoids  belong  to  two  plexuses, 
between  which,  ordinarily,  there  is  not  a  free  anastomosis.  The  inferior 
or  external  haemorrhoidal  plexus  is  situated  in  the  last  portion  of  the 
rectum,  within  about  one  inch  of  the  anus,  and  the  blood  from  this  part 
returns  by  way  of  the  middle  and  inferior  haemorrhoidal  veins  to  the 
iliacs,  and  thence  by  the  inferior  cava  to  the  heart.  The  superior  or  in- 
ternal plexus  occupies  the  rectum  above  this  point,  and  fi-om  this  por- 
tion the  blood  returns  by  the  portal  system,  passing  through  the  liver. 

In  their  incipiency,  external  JicBmorrhoids  are  simple  varicosities  of 
the  inferior  plexus.  Later,  as  a  result  of  engorgement  and  repeated  in- 
flammation, the  walls  become  thickened  from  the  presence  of  newly 
formed  connective  tissue,  which,  in  the  process  of  contraction  peculiar 
to  this  product  of  inflammation,  often  causes  obliteration  of  the  vein 
within  the  tumor.  The  remains  of  these  tumors  are  seen  in  almost  all 
cases  of  chi'onic  external  haemon-hoids,  where  they  appear  as  tags  of 
thickened  skin  of  variable  size  and  shape,  collected  around  the  margin 
of  the  anus. 

Internal  hcemorrhoids  of  recent  develoiDment  are  also  varicosities  of 
the  internal  or  portal  plexus,  but  when  of  long  duration  the  tumors 
very  frequently  contain  arterioles  of  considerable  size.  The  mucous 
membrane  of  the  deeper  portions  of  the  rectum  is  at  times  studded  with 
small,  raspberry-like  elevations,  which  bleed  profusely,  are  found  to 
contain  a  rich  network  of  capillaries,  and  for  this  reason  are  termed 
capillary  haemorrhoids. 

External  Hcemorrhoids — Acute  and  Chronic. — This  form  of  tumor, 
commonly  known  as  "dry  piles,"  is  of  frequent  occurrence.  Few  indi- 
viduals live  beyond  the  age  of  forty  without  being  affected  with  this 
lesion.  The  chief  cause  is  habitual  constipation  and  the  over-distention 
of  the  lower  portion  of  the  rectum  in  the  act  of  defecation.  Prolonged 
straining  at  stool,  even  without  the  discharge  of  fecal  matter,  will  also 
aid  in  the  development  of  piles.  Gravitation  by  reason  of  the  erect 
posture  is  also  entitled  to  a  consideration  in  the  aetiology  of  haemor- 
rhoids, since  man  is  the  only  animal  thus  afl'ected.  Pressure  upon  the 
iliac  veins  or  the  inferior  cava  by  the  gravid  uterus,  or  any  form  of 
tumor,  will  also  aid  in  producing  varicosities  of  the  haemorrhoidal  veins 
as  well  as  in  those  of  the  lower  extremities. 

A  patient  who  is  suffering  from  an  acute  external  haemorrhoidal  tu- 
mor will  usually  give  a  history  of  constipation  and  straining  at  stool, 
with  an  unnatural  sense  of  fullness  and  heaviness  about  the  anus,  and 
of  considerable  pain  whUe  the  evacuation  is  taking  place,  for  several 
days  before  the  protrusion  is  noticed.     Immediately  after  an  evacuation 


612  A  TEXT-BOOK   ON   SURGERY. 

a  swelling  is  noticed  just  outside  of  the  anus  which  is  painful  to  the 
touch,  and  which  can  not  be  pushed  into  the  bowel.  Upon  inspection, 
a  recent  external  hsemorrhoidal  tumor  usually  appears  tense  and  glis- 
tening on  the  surface,  and  red  or  reddish-blue  in  color.  It  is  partly 
within  and  partly  outside  of  the  anus.  There  may  be  a  single  swell- 
ing, which  is  spherical  in  shape,  or  it  may  be  crescentic,  occupying  half 
of  the  anal  margin.  If  not  observed  until  after  several  days  have 
elapsed,  and  when  the  tension  or  partial  strangulation  has  not  been  re- 
lieved, ulceration  may  have  occurred,  with  intlammation  and  induration 
of  the  tissues  near  the  base  of  the  tumor.  In  other  instances  which  do 
not  come  under  the  observation  of  a  physician,  the  patient  goes  to  bed, 
pushes  the  tumor  vdthin  the  anus,  the  symptoms  disappear  within  a  day 
or  two,  to  recur  again  and  again  under  the  same  conditions. 

Chronic  external  JicBmorrhoids  differ  from  the  acute  form  just  de- 
scribed in  the  following  particulars  :  They  are  brown  or  bluish  in  color, 
are  not  tense  nor  painful,  are  loose  and  flabby,  and  have  a  thickened, 
leathery  feel  when  pinched  between  the  fingers. 

Treatment. — The  treatment  may  be  palliative  or  curative.  If  the 
palliative  treatment  is  determined  upon,  the  immediate  indication  is  to 
relieve  the  tension  in  the  tumor  by  returning  it  within  the  anus.  The 
patient  should  be  placed  in  the  left  lateral  or  knee-shoulder  position, 
the  protruded  portion  and  fingers  of  the  operator  thoroughly  lubricated, 
and  reduction  eifected  by  well-directed  pressiire,  combined  with  slight 
dilatation  of  the  sphincter.  If  the  tumor  is  so  large  that  it  can  not  be 
reduced,  relief  may  be  obtained  by  the  local  application  of  the  ice-bag, 
or  cold  water.  The  majority  of  cases  will  be  relieved  temporarily  by 
this  treatment,  and  a  certain  proportion  may  not  sufi'er  a  relapse,  but 
the  rule  is  for  the  tumor  to  recur  from  time  to  time  ^^ntil  it  is  cured 
finally  by  an  operation. 

In  operating  for  the  cure  of  external  piles,  the  ligature  is  rarely  de- 
manded. If  the  masses  are  extensive,  it  will  be  advisable  to  excise  them 
after  the  method  of  Whitehead.  If  there  is  a  single  tumor  or  one  or  two 
small  haemorrhoids  which  are  inflamed,  immediate  relief  may  be  obtained 
by  incising  it.  This  procedure  may  be  rendered  painless  by  the  follow- 
ing method :  The  smallest  hypodermic  needle  is  attached  to  the  syringe, 
containing  about  ill  xv  of  a  4-per-cent  solution  of  cocaine  hydrochlorate. 
The  needle  is  introduced  into  one  side  of  the  tumor  at  its  base  to  tUe 
depth  of  about  one  eighth  of  an  inch,  and  three  or  four  minims  of  the 
solution  forced  out ;  a  minute  later  it  is  carried  farther,  and  the  manoeu- 
vre repeated  until  the  needle  has  completely  transfixed  the  mass,  and  all 
the  fiuid  injected.  Within  five  minutes  the  aufesthesia  is  usually  so 
complete  that  the  tnmor  can  be  laid  open  with  the  bistoury  without 
pain.  The  bleeding  is  insignificant,  and  is  easily  arrested  by  packing  a 
tuft  of  borated  cotton  or  lint  into  the  wound.  No  after-treatment  is 
required.     The  wound  heals  after  five  or  six  days  and  the  pile  is  cured. 

Old  external  piles  may  be  removed  by  grasping  the  tumor  with  a  pair 
of  mouse- tooth  forceps  and  clipping  it  off  near  its  base  with  a  pair  of 
scissors  curved  on  the  flat.     Local  anaesthesia  should  also  be  employed. 


HEMORRHOIDS.  613 

Internal  HcBmorrhoids. — Constipation,  over-distention  of  the  rectum, 
and  prolonged  straining  at  stool  must  also  be  considered  as  among  the 
principal  causes  of  internal  as  well  as  external  piles.  In  addition  to 
these,  any  disease  of  the  liver  which  causes  a  retardation  of  the  return 
of  blood  through  the  portal  circulation  will  aid  in  producing  internal 
hgemorrhoids. 

Pressure  upon  the  portal  vein,  or  upon  the  inferior  mesenteric  vein, 
whether  due  to  an  overloaded  condition  of  the  alimentary  canal,  or  a 
tumor,  will  produce  the  same  effect. 

Symptoms. — Internal  piles,  as  a  rule,  cause  little  or  no  pain  or  an- 
noyance until  they  are  sufficiently  developed  to  be  caught  in  the  grip 
of  the  sphincter,  or  are  protruded  through  the  anus.  Previous  to  their 
descent,  however,  a  variable  amount  of  bleeding  has  usually  occurred, 
often  enough  to  attract  the  attention  and  excite  the  alarm  of  the  patient. 
This  is  especially  true  of  the  arterio-venous  and  capillary  tumor,  al- 
though the  venous  tumor  not  infrequently  gives  rise  to  considerable 
haemorrhage. 

Upon  digital  examination  the  presence  of  the  hfemon-hoids  may  be 
easily  recognized,  and  ocular  demonstration  may  be  made  by  the  care- 
ful dilatation  of  the  sphincter  with  the  Sims  rectal  speculum.  If  a  free 
enema  of  warm  water  be  administered,  the  tumors  will  usually  protrude 
with  the  discharge  of  the  water  if  the  patient  is  placed  in  the  squatting 
posture,  and  is  directed  to  make  a  strong  expulsive  effort. 

Treatment. — Venous  and  arterio-venous  internal  hfemorrhoids  may 
be  cured  by  one  of  three  methods — the  ligature,  by  excision,  the  clamp, 
and  the  injection  of  carbolic  acid ;  the  cai^illary  variety  by  the  mild 
application  of  the  caiitery  or  nitric  acid. 

Of  these  methods,  the  ligature  and  excision  are  by  far  the  more  satis- 
factory and  thorough  operations.  The  clamp  is  preferred  by  some  oper- 
ators, but  in  the  opinion  of  the  author  is  inferior  to  either  of  the  above. 
It  requires  a  special  instrument  and  a  cautery  apparatus,  while  the  other 
procedures  are  done  with  the  ordinary  instruments  of  the  general  prac- 
titioner. Moreover,  the  danger  of  haemorrhage  is  greater  after  the 
clamp.  Either  of  these  three  methods  is  preferable  to  the  injection  of 
carbolic  acid.  The  objections  to  this  operation  are,  that  it  does  not 
always  succeed,  it  requires  a  long  time — several  weeks,  and  at  times 
months — in  effecting  a  cure,  peri-proctitis  and  abscess  of  the  ischio- 
rectal fossa  may  ensue,  and  hepatic  emboKsm,  with  abscess,  is,  however 
remote,  a  possibility.  Not  infrequently  ulcer  of  the  bowel  results, 
which  of  itself  requires  to  be  cured.  In  its  favor  it  may  be  said  that 
the  treatment  can  be  carried  on  without  ether  narcosis,  in  almost  all  cases 
without  going  to  bed,  and  is  not,  as  a  rule,  accompanied  by  great  pain. 

As  between  the  ligature  and  excision  it  may  be  concluded  that  the 
former  is  bloodless,  simple  in  technique,  satisfactory  in  results,  and  can 
be  done  in  about  one  third  of  the  time  required  for  excision.  White- 
head's operation,  while  more  bloody,  yields  a  cure  equally  radical, 
quicker  by  from  five  to  ten  days,  and  is  somewhat  less  painful  for  the 
first  five  days  after  the  operation,  and  is  more  cleanly.     In  my  opinion, 


614  A  TEXT-BOOK   ON   SURGERY. 

the  ligature  will  continue  to  be  more  generally  practiced  than  all  other 
methods  for  the  radical  cure  of  haemorrhoids. 

Operation  hy  the  Ligature. — The  preparation  of  the  patient  is  the 
same  as  in  other  operations  about  the  rectum.  When  fully  ansesthe- 
tized,  the  lithotomy  position  should  be  preferred,  or,  if  help  is  scarce,  or 
the  convenience  of  the  operator  is  better  suited,  the  patient  may  be 
placed  upon  the  left  side,  with  the  left  arm  behind  the  body  and  the 
thighs  and  legs  flexed. 

The  first  step  is  the  dilatation  of  the  sphincter,  which  is  accomplished 
by  introducing  the  thumbs  or  first  and  second  fingers  of  each  hand 
and  stretching  the  muscle  in  all  directions,  until  relaxation  is  complete. 
This  should  not  be  too  rapidly  effected,  for  fear  of  tearing  the  fibers.  A 
soft  sponge  secured  by  a  strong  silk  thread  is  carried  into  the  rectum 
above  the  piles,  in  order  to  prevent  the  descent  of  fecal  matter  ;  or  a 
Barnes's  dilator,  as  recommended  by  Dr.  Willis  P.  King,  may  be  intro- 
duced and  then  filled  with  water.  The  bowel  should  then  be  irrigated 
with  l-to-5000  sublimate  solution. 

Seated  in  front  of  the  patient,  the  operator — presuming  that  the 
tumors  are  present  in  the  entire  anal  circumference — introduces  one  or 
two  fingers  of  his  left  hand  and  by  pressure  with  the  palmar  surface  of 
the  fingers  from  above  downward,  brings  the  mucous  membrane,  which 
lines  the  hsemorrhoidal  tumors  and  these  tumors  well  down  to  the  mar- 
gin of  the  anus.  In  this  way  he  is  perfectly  able  to  discover  how  high 
up  the  needle  and  ligature  must  be  introduced  in  order  to  cut  off  all  the 
varicosities. 

With  a  pair  of  scissors,  or  a  sharp,  small-bladed  knife,  he  now  makes 
an  incision  at  the  muco-cutaneous  junction,  and  this  incision  should 
extend  through  the  skin  and  follow  somewhat  the  irregularities  of  the 
various  tumors. 

This  done,  a  large,  strong,  half-curved  needle,  armed  with  a  long 
doubled  Chinese  twisted-silk  ligature,  so  strong  that  the  operator  has 
essayed  in  vain  to  break  it,  and  held  by  a  firm  holder,  is  introduced  as 
follows  :  For  the  patient's  left  side  (operator's  right)  the  needle,  con- 
cavity toward  the  operator,  is  introduced  into  the  incision  just  made  and 
is  carried  to  the  depth  of  about  one  eighth  to  one  quarter  inch — just 
enough  to  well  engage  the  point.  With  the  fingers  of  the  left  hand 
dragging  down  the  tumor,  and  the  base  of  the  hemorrhoid  thus  well 
defined,  it  is  evident  that,  if  the  needle  were  plunged  directly  through 
to  the  base  of  the  tumor,  it  would  jDass  through  or  so  near  to  the 
peripheral  fibers  of  the  sishincter-ani  muscle  that,  as  the  ligature  was 
tightened,  these  would  be  sacrificed  and  the  integrity  of  this  muscle 
impaired. 

Therefore,  as  soon  as  the  needle  is  engaged  as  just  described,  enough 
to  clear  the  sphincter,  it  is  turned  completely  over,  so  that  the  convexity 
is  toward  the  operator,  and  is  then  carried  along  the  inner  surface  of  the 
sphincter,  well  away  from  the  mucous  membrane,  until  the  point  is  felt 
to  touch  the  level  of  the  finger,  which  all  the  while  has  remained  fixed  at 
the  base  of  the  tumor.     It  is  again  turned,  concavity  to  the  operatox', 


HEMORRHOIDS.  615 

which  brings  the  point  through  the  mircons  membrane  upon  the  finger 
located  there,  which  finger  now  guides  the  point  of  the  instrument  out  at 
the  anus.  Dividing  both  threads  and  liberating  the  needle,  the  double 
ligatures  are  ready  for  tying.  At  this  step  of  the  operation  two  impor- 
tant points  are  to  be  considered :  1.  That  the  ligatures  be  crossed.  2. 
That  not  too  much  tissue  be  allowed  in  the  grasp  of  each  thread.  The 
threads  may  be  disassociated  by  traction  on  the  ends,  and  then  inter- 
locked by  carrying  on  one  side  of  the  tumor  one  thread  over  the  other. 
Not  more  than  three  quarters  of  an  inch  of  the  anal  cii'cumference  should 
be  cut  off  by  one  set  of  double  ligatures.  Measuring  then  about  one  half 
of  this  distance  on  each  side  of  the  point  traversed  by  the  threads,  cut 
with  the  scissors  directly  through  the  anal  margin  down  to  the  level  of 
the  encircling  incision  made  at  the  muco-cutaneous  junction.  When 
this  perpendicular  incision  passes  through  a  hfemorrhoid,  the  bleeding 
should  be  prevented  by  applying  a  forceps  before  the  cut  is  made.  The 
entire  hjemorrhoidal  circumference  is  thus  divided  into  segments  of 
about  three  quarters  of  an  inch  in  length  each. 

The  ligatures  are  now  very  tightly  tied  by  the  reef-knot  (Fig.  Ill), 
the  ends  left  long  and  the  group  of  four  threads  looped  together.  If  the 
operator  is  not  ambidextrous,  the  ligatures  for  the  patient's  right  side 
(operator's  left  hand)  may  be  introduced  from  within  out. 

Each  tumor  or  section  is  treated  in  the  same  manner,  until  all  are  com- 
pleted, Avhen  all  the  strangulated  tissues  are  cut  away  with  the  curved 
scissors,  leaving  stump  enough  to  hold  the  loops  securely.  The  threads 
are  now  cut  off  one  inch  from  the  knots,  the  rectal  pliTg  withdrawn,  a 
medium-size  rubber  tube  four  inches  long  is  wrapjsed  with  iodoformized 
gauze,  lubricated  \\"ith  vaseline  and  introduced  for  three  inches  into  the 
rectum,  and  a  pad  of  gauze  and  cotton  and  T-bandage  applied. 

It  is  advisable  to  give  a  hypodermic  or  a  suppository  of  morphia  as 
the  operation  is  being  completed,  as  pain  is  present  in  almost  all  cases. 

The  dressing  may  be  removed  and  the  bowels  moved  by  enema  on  the 
fourth  or  fifth  day.  The  catheter  is  frequently  required  for  the  first  few 
days  after  the  operation.  The  ligatures  come  away  about  the  twelfth 
day,  and  the  recovery  is  complete  about  the  third  week. 

Excision  of  the  Hemorrhoidal  Varicosities,  together  with  a  Circle  of 
the  Terminal  Mucous  Membrane  of  the  Rectum, —  Whitehead'' s  Opera- 
tion.—T^q  preparation  of  the  patient  and  position  on  the  table  are  the 
same  as  just  given. 

The  sphincters  are  thoroughly  paralyzed  by  digital  stretching,  so  that 
they  have  no  grip,  and  permit  the  haemorrhoids  and  any  prolapse  there 
may  be  to  descend  without  the  slightest  impediment. 

By  the  xise  of  scissors  and  dissecting  forceps  the  mucous  membrane  is 
divided  at  its  junction  with  the  skin  round  the  entire  circumference  of 
the  bowel,  every  irregularity  of  the  skin  being  carefully  followed. 

The  external  and  the  commencement  of  the  internal  sphincters  are 
then  exposed  by  rapid  dissection,  and  the  mucous  membrane  and 
attached  hsemorrhoids  thus  separated  from  the  submucous  bed  on  which 
they  rested,  are  pulled  bodily  down,  any  undivided  points  of  resistance 


616  A  TEXT-BOOK   ON   SURGERY. 

being  snipped  across,  and  the  hfemorrlioids  brought  below  the  margin  of 
the  anus. 

The  mucous  membrane  above  the  haemorrhoids  is  now  divided  trans- 
versely in  successive  stages,  and  the  free  margin  of  the  severed  membrane 
is  attached  as  soon  as  divided  to  the  free  margin  of  the  skin  below  by  a 
suitable  number  of  silk  sutures.  The  complete  ring  of  pile-bearing 
mucous  membrane  is  thus  removed. 

Whitehead  advises  that  torsion  be  applied  to  all  bleeding  points,  as 
the  operation  proceeds.  The  dissection  is  comparatively  dry,  if  the  oper- 
ator keeps  close  to  the  inner  surface  of  the  external  sphincter,  and  works 
with  the  finger  or  the  dull-pointed  scissors. 

The  silk  sutures,  inserted  as  the  rim  of  the  mucous  membrane  is 
finally  snipped  off,  prevent  any  great  amount  of  haemorrhage. 

Iodoform  may  be  insufflated  upon  the  raw  surfaces,  and  an  ordinary 
T-bandage  dressing  applied.  The  sutures  are  allowed  to  come  away  of 
their  own  accord. 

The  operation  with  the  clamp  and  cautery  is  performed  as  follows : 
After  stretching  the  sphincter,  the  tumor  is  drawn  out  and  grasped  at  its 
base  between  the  jaws  of  the  clamp  (Pig.  562),  and  the  blades  closed  by 
tightenina:  the  screw  in  the  handles  until  the  hsemorrhoid  is  strangu- 


Fio.  562. — Smith's  hsemorrhoidal  clamp  (ivory-plated). 

lated.  It  is  advised  to  grasp  the  hsemorrhoids  in  such  a  manner  that  the 
instrument  points  directly  up  the  bowel.  With  the  scissors  the  mass  is 
cut  away  about  one  fourth  of  an  inch  external  to  the  clamp,  and  the  cut 
surface  thoroughly  cauterized  with  the  Paquelin  or  the  actual  cautery. 
The  ivory  plates  upon  the  jaws  of  the  clamp  protect  the  mucous  mem- 
brane of  the  bowel  from  being  burned.  When  this  is  done,  the  blades 
should  be  slowly  separated,  and,  if  any  oozing  is  seen,  the  bleeding  point 
should  be  again  touched  with  the  cautery.  The  after-treatment  is  the 
same  as  for  the  preceding  operation. 

Injection  with  Carbolic  Acid. — The  haemorrhoid  to  be  operated  upon 
should  be  exposed  with  the  speculum  or  drawn  well  out  with  the  fingers. 
If  it  is  a  long  pedunculated  tumor,  the  needle  should  be  introduced 
from  the  point  to  near  its  base.  If  it  is  round  or  oval  in  shape,  the 
needle  should  pass  through  the  longer  diameter  of  the  mass  near  the 
level  of  the  mucous  membrane  of  the  bowel.  The  mucous  membrane 
and  integument  should  be  well  covered  with  vaseline  to  prevent  excoria- 
tion from  the  acid  which  may  leak  from  the  syringe  or  ooze  out  of  the 
tumor. 

The  ordinary  hypodermic  syringe  will  answer  every  pur^jose  if  one  or 


HEMORRHOIDS.  617 

two  extra  long  and  fine  needles  are  secured.     In  Fig.  563  is  shown  an 
apparatus  especially  designed  for  this  operation. 

From  ten  to  twenty  minims  of  a  4-per-cent  cocaine  solution  (the  quan- 
tity being  determined  by  the  size  of  the  tumor)  are  first  thrown  in,  and 
the  instrument  unscrewed  from  the  needle,  leaving  this  sticking  in  the 
tumor.  The  carbolic-acid  solution  is  now  drawn  into  the  syringe,  and 
this  is  again  screwed  on  to  the  needle.  After  from  one  to  three  minutes 
the  anaesthesia  wiU  be  complete,  and  the  solution  should  be  forced  slowly 
into  the  tumor,  being  distributed  in  the  line  in  which  the  cocaine  was 
injected.  It  is  advisable  to  operate  upon  a  single  hsemorrhoid  at  each 
operation.  The  strength  of  the  solution  and  the  quantity  to  be  em- 
ployed will  be  determined  by  the  size  and  condition  of  the  tumor.     If  a 


Fig    5  3  — Ktlbcy  s  1  'emorrl  o  ill  sj rm,e 

rapid  sloughing  of  the  mass  is  desired,  this  result  may  be  secured  by 
using  a  solution  of  equal  parts  glycerin  and  carbolic  acid,  and  from  five 
to  twenty  minims  should  be  introduced  unless  the  hsemorrhoid  is  un- 
usually large.  After  injecting  a  solution  of  this  strength  the  tumor  be- 
comes hard,  and  changes  to  a  blue  or  bluish-gray  color.  In  from  twenty- 
four  to  forty-eight  hours  the  mass  sloughs  away,  and  by  the  fourth  or 
fifth  day  has  disappeared,  leaving  only  a  small  ulcer  in  the  mucous  mem- 
brane corresponding  to  the  base  of  the  heemorrhoid.  If  a  10-per-cent 
solution  is  employed,  sloughing  rarely  occurs,  and  a  much  greater  quan- 
tity— from  twenty  to  thirty  minims — can  be  injected.  A  mild  degree  of 
inflammation  is  established,  followed  within  a  few  days  by  a  diminution 
in  the  size  of  the  tumor,  which,  in  a  certain  proportion  of  cases,  grad- 
ually undergoes  atrophy  and  entirely  disappears.  The  degree  of  pain 
following  the  injection  of  the  stronger  solution,  after  the  temporary 
anaesthesia  secured  by  the  cocaine  has  passed  ofl',  varies  with  different 
individuals.  In  some  of  my  cases  it  was  so  insignificant  that  the  patients 
went  immediately  about  their  vocations.  In  others  the  same  solution 
caused  great  annoyance  and  considerable,  though  never  alarming,  inflam- 


618  A  TEXT-BOOK   ON   SURGERY. 

mation.  The  milder  solutions  are  also  painful  at  times,  though  in  a 
less  degree.  In  choosing  between  the  weak  and  strong  solutions  just 
given,  the  operator  must  be  guided  chiefly  by  the  time  in  which  it  is 
desired  to  effect  a  cure.  If  expedition  is  demanded,  the  strong  injec- 
tions should  be  employed  ;  if  not,  the  weak  solution  is  preferable  to 
begin  with,  and,  if  necessary,  this  may  be  increased  in  strength  at  a 
subsequent  operation. 

In  capillary  TicBinorrhoids  the  chief  symptom  is  hsemorrhage.  The 
bleeding  occurs  with  and  after  each  stool,  or  may  follow  violent  exercise 
or  straining.  If  the  finger  is  carried  into  the  bowel,  no  tumors  are  felt, 
and  there  is  usually  no  tenesmus.  If  the  speculum  is  employed,  the 
mucous  membrane  will  be  seen  to  be  studded  with  bleeding  points  or 
tufts  projecting  a  slight  distance  from  the  normal  level  of  the  lining 
membrane  of  the  rectum.  They  are  red,  not  unlike  small  raspberries 
in  appearance,  and  bleed  profusely  at  the  slightest  provocation.  They 
are  really  new  formations  or  chronic  granulation-tissue,  rich  in  capillary 
loops. 

The  treatment  consists  in  dilatation  of  the  anus  and  rectum  with  the 
speculum,  and  in  touching  the  bleeding  points  with  the  Paquelin  cau- 
tery until  all  bleeding  ceases.  If  the  cautery  is  not  at  hand,  pure  nitric 
acid  should  be  applied. 


CHAPTER  XIX. 

GEN"ITO-UEI]SrART   OEGANS. 

Kidneys. — Certain  diseased  conditions  of  the  kidneys,  resulting 
cliiefly  from  traumatism,  but  in  some  instances  idiopathic  in  origin, 
demand  a  careful  consideration,  and  at  times  active  interference,  at  the 
hands  of  the  surgeon. 

Wounds. — Solutions  of  continuity  in  these  organs,  either  as  a  result 
of  concussion  or  from  the  penetration  of  a  foreign  body,  are  among  the 
most  dangerous  visceral  lesions.  Rupture  of  the  kidney  occurs  not  only 
from  violence  applied  immediately  over  the  anatomical  seat  of  this  organ, 
but  indirectly,  as  from  a  fall  on  the  head  or  feet.  The  conditions  which 
result  are  practically  identical,  whether  there  is  a  penetrating  wound  or 
not.  Haemorrhage  is  immediate,  and  is  proportionate  to  the  extent  of 
kidney  involved  and  to  the  vascularity  of  the  part  injured.  Shock  is 
usually  well  marked.  Vomiting  is  present,  with  pallor,  cold  perspira- 
tion, rapid  and  weak  pulse.  Pain,  if  severe,  is  felt  in  the  region  of  the 
organ,  and  is  transmitted  in  the  direction  of  the  ureters,  down  the  leg, 
and  into  the  testicle  of  the  injiired  side  in  the  male,  which  organ  is  usu- 
ally drawn  up  toward  the  exteimal  ring.  Extravasation  of  urine  takes 
place,  and,  when  the  capsule  is  torn,  finds  its  way  into  the  loose  areolar 
tissue  of  the  retroperitoneal  space.  Haemorrhage  occurs  in  the  same  way, 
as  well  as  into  the  uriniferous  tubules  and  pelvis  of  the  kidney.  The 
organ  may  be  disj)laced  by  concussion,  usually  traveling  downward  and 
toward  the  median  line. 

The  symptoms.,  although  varying  with  the  extent  of  the  lesion,  are 
usually  those  of  profound  shock.  Pain,  not  only  local,  but  extending 
in  the  direction  just  described,  together  with  the  presence  of  bloody 
urine,  in  a  patient  who  has  received  a  wound  in  the  lumbar  region,  or  a 
severe  concussion,  and  who  has  no  bladder  or  urethral  disease  to  account 
for  haematuria,  are  symptoms  which  point  quite  clearly  to  the  nature  of 
the  injury.  Partial  suppression  of  urine  is  not  uncommon.  A  marked 
elevation  of  temperature  usually  follows  the  reaction  from  shock.  The 
febiile  movement  is  chiefly  due  to  the  inflammation  which  follows  the 
escape  of  urine  into  the  retroperitoneal  space.  With  the  advent  of 
pus-formation,  local  tenderness  is  increased,  the  area  of  inflammation 
spreads,  the  more  superficial  structures  become  tense,  the  integument  is 
reddened,  and  rigors  or  chills  occur,  followed  by  exacerbations  of  tem- 
perature. 


620  A  TEXT-BOOK  ON  SURGERY. 

The  prognosis  is  unfavorable,  but  must  chiefly  depend  upon  the  ex- 
tent of  the  injury,  as  determined  by  the  earlier  symptoms. 

The  treatment  may  be  radical  or  conservative.  Immediate  operation 
within  the  period  of  shock  is  scarcely  to  be  thought  of.  If  the  symptoms 
of  heemorrhage  are  alarming,  deligation  of  the  extremities  should  be 
practiced,  and,  if  syncope  is  still  threatened,  the  intra-venous  injection 
of  a  saline  solution  should  be  performed.  Direct  operative  interference, 
by  cutting  down  upon  the  wounded  organ,  will  be  rarely  called  for. 

With  the  earliest  symptom  of  abscess  an  exploratory  incision  should 
be  made.  It  is  advisable  to  insert  the  aspirator-needle  at  the  points  of 
greatest  tenderness  and  induration,  and,  if  pus  is  discovered,  the  incision 
should  be  made  along  the  needle  as  a  guide.  If  pus  can  not  be  obtained 
by  using  the  aspirator,  the  incision  is  still  indicated  if  the  symptoms  of 
sepsis  above  given  are  present.  The  organ  may  be  readily  reached  by 
cutting  parallel  with,  and  about  three  inches  and  a  half  external  to,  the 
spines  of  the  lumbar  vertebrse.  The  kidney  is  located  just  in  front  of 
the  outer  border  of  the  quadratus  lumborum  muscle,  its  lower  extremity 
reaching  down  to  the  level  of  the  umbilicus. 

If  an  abscess  is  found,  it  should  be  irrigated  with  l-to-5000-sublimate 
solution,  and  free  drainage  established. 

The  kidney  is  often  the  seat  of  morbid  changes,  which  occur  partly 
from  internal  violence  and  partly  from  idiopathic  causes,  which  may  at 
times  justify  the  surgical  invasion  of  this  organ.  Pyelitis,  pyonephrosis, 
calculus,  hj'-dronephrosis,  and  certain  new  formations,  as  cysts,  carci- 
noma, sarcoma,  rhabdomyoma,  adenoma,  angioma,  tuberculosis,  and 
gumma,  are  among  the  chief  diseases  of  a  surgical  nature. 

Pyelitis,  or  inflammation  of  the  pelvis  of  the  kidney,  may  be  caused 
by  the  irritating  effects  of  calculi  in  the  caUces  or  pelvis  of  this  organ, 
which  do  not  escape  readily  into  and  through  the  ureter  ;  to  over-disten- 
tion,  resulting  from  urethral,  vesical,  or  ureteral  obstruction,  or  by  exten- 
sion of  an  inflammatory  i^rocess  from  below  upward  {urethritis,  cystitis, 
ureteritis).  It  is  less  frequently  caused  by  direct  violence  from  vdthout, 
or  may  be  part  of  an  idiopathic  perinephritis.  It  is  readily  understood 
how  a  stricture  of  the  urethra,  enlarged  prostate,  or  an  obstructed  ureter 
would  force  the  urine  back  upon  the  kidney,  causing,  in  severe  and 
chronic  cases,  destruction  of  this  organ,  and  a  pyelitis  before  this  could 
occur.  In  like  manner,  the  inflammation  in  a  urethritis  or  cystitis  may 
travel  along  the  ureter  until  the  pelvis  of  the  kidney  is  involved. 

The  diagnosis  of  pyelitis  can  not  be  so  readily  made  out  by  the  symp- 
toms referable  to  the  inflammation  in  the  pelvis  proper,  as  by  a  study  of 
the  conditions  which  precede  it.  Pain,  which  is  present  in  this  disease, 
is  present  in  a  variety  of  kidney  lesions,  and,  as  in  neuralgia  of  this  organ 
[nepTiralgia),  it  is  met  with  when  no  symptoms  of  inflammation  exist. 
If,  after  an  attack  of  renal  colic,  pain  of  a  more  constant  and  less  excru- 
ciating character  is  felt,  deep  in  the  lumbar  region,  being  on  one  side 
only,  and  on  that  side  upon  which  the  colic  occurred,  and  if  pus  is  pres- 
ent in  the  urine  where  no  cystitis  or  urethritis  exists,  pyelitis  should  be 
strongly  suspected.     Persisting  pain  in  this  region,  in  a  patient  suffering 


GENITO-URIXART   ORGANS.  621 

from  obstruction  in  the  urinary  track,  beyond  the  pelvis  of  tlie  kidney, 
is  also  strong  evidence  in  favor  of  pyelitis,  not-\vithstanding  that  the  pus 
present  is  known  to  come  from  other  sources.  Added  to  the  above,  the 
febrile  movement,  and  rigors  of  the  inflammatory  process,  the  frequent 
micturition,  the  exaggeration  of  pain  upon  pointed  and  deep  pressure, 
and,  in  the  later  stages,  the  r)resence  of  a  tumor,  caused  by  the  dilated 
organ,  and  the  diagnosis  of  pyelitis  may  be  determined. 

In  cases  of  pyelitis  "with  complete  obstruction,  pus  is  retained,  and, 
together  with  the  urine  excreted  by  the  tubules  not  yet  destroyed,  dis- 
tends the  pelvis,  together  with  the  kidney,  causing  a  hydro-pyo-nephro- 
sis,  ultimately  opening  into  the  peritonaeum,  pleura,  or  retroperitoneal 
space,  or  it  may  open  through  the  integument  in  the  lumbar  region,  or 
near  Poupart's  ligament. 

Treatment. — This  must  be  directed  to  the  relief  of  pain,  to  the  removal 
of  the  cause  of  the  disease,  and  to  the  maintenance  of  the  j^atient's  powers 
of  resistance  by  Judicious  feeding.  The  relief  of  pain  is  obtained  by  the 
employment  of  anodynes  and  by  counter-irritation,  as  by  sinapisms,  hot 
cloths,  and  cups  to  the  lumbar  region.  When  the  disease  is  obstinate, 
and  the  destruction  of  the  kidney  is  evident,  incision  should  be  made,  and 
free  drainage  secured,  or,  if  the  patient's  condition  will  justify  a  more 
formidable  procedure,  the  diseased  organ  should  be  removed. 

Hydronephrosis  is  both  a  congenital  and  an  acquired  lesion.  In  the 
congenital  form  the  arrest  of  development  may  be  in  the  ureter  or  urethra, 
with  partial  or  complete  occlusion  of  one  or  the  other  of  these  organs. 
The  urine,  being  iinable  to  escape,  accumulates  and  distends  the  pelvis 
and  calices,  causing  destruction  of  the  tubules  and  Malpighian  tufts,  and 
terminating,  if  the  obstruction  is  sufficiently  prolonged,  in  a  cyst,  the 
wall  of  which  is  composed  of  the  peh-is  and  capsule  of  the  kidney.  As 
stated  above,  obstruction  of  the  urethra  usually  causes  inflammation  of 
the  pelvis,  the  result  being  not  a  simple  hydronephrosis,  but  a  hydro- 
pyo-nephrosis.  Simple  hydronephrosis  occurs  in  rare  cases,  when  the 
obstruction  comes  on  gradually.  In  congenital  occlusion  the  distention 
of  the  pelvis,  the  atrophy  of  the  kidney,  and  the  development  of  a  large 
cyst  may  occur  without  inflammation.  The  character  of  the  obstruction 
will  vary.  Calculus  in  the  ureter,  or  stricture  resulting  from  the  inflam- 
mation caused  by  the  descent  of  a  stone  to  the  bladcler,  pressure  by  a 
neoplasm  or  another  organ,  and  all  lesions  of  the  bladder  and  urethra 
which  retard  or  arrest  the  flow  of  urine,  may  produce  this  condition. 
At  times  the  tumor  is  so  small  that  it  may  escape  observation,  or  it 
may  almost  fill  the  abdominal  cavity. 

The  diagnosis  is  rarely  made  unless  the  cyst  is  sufiiciently  large  to 
attract  attention.  The  presence  of  a  fluctuating  tumor  in  the  lumbar 
region  will  serve  to  suggest  hydronephrosis,  and  the  exploration  of  the 
cyst  with  a  very  fine  needle  will  exhaust,  by  aspiration,  a  fluid  which, 
under  the  microscope,  will  demonstrate  the  exact  nature  of  the  tumor. 
In  those  cases  where  the  obstruction  is  not  permanent,  but  recurs  at 
intervals,  the  disappearance  of  the  swelling,  with  the  discharge  of  an 
extraordinary  quantity  of  urine,  may  be  considered  almost  a  positive 


622  A  TEXT-BOOK  ON  SURGERY. 

symptom  of  this  condition.  When  the  cause  is  vesical  or  urethral,  both 
kidneys  will  be  affected.  Ursemic  symptoms  may  occur,  and  are  present 
in  the  latter  stages,  when  the  destruction  of  the  tubules  is  general.  If  the 
obstruction  is  gradual,  the  tolerance  of  uraemia  is  at  times  great,  and 
when  only  a  single  kidney  is  affected,  especially  if  the  unilateral  occlu- 
sion is  not  sudden,  the  other  organ  will,  in  most  cases,  assume  a  functional 
activity  sufficient  for  the  work  of  both  kidneys. 

Hydronephrosis  may  be  mistaken  for  hydatid  cysts  of  this  organ, 
for  ovarian  cysts,  cyst  of  the  pancreas  and  spleen,  or  for  abdominal 
dropsy.  In  abdominal  dropsy  the  fluid  gravitates  to  the  pelvis  and 
changes  with  the  different  positions  assumed.  Liver-disease  almost 
always  precedes  ascites.  Cysts  of  the  spleen  and  pancreas  are  rare, 
and  the  early  history  of  their  development  will  point  to  an  origin  away 
from  the  kidney.  In  hydatid  cysts  of  the  kidney  the  only  positive 
differentiation  is  iu  the  recognition  of  the  hydatid  vesicles  in  the 
urine. 

Treatment. — In  mild  cases,  whether  the  disease  is  double  or  single, 
operative  interference  is  not  demanded.  In  stricture  of  the  urethra  or 
enlarged  prostate,  the  removal  of  the  obstruction  is  imperative.  Symp- 
toms of  uraemia  call  for  the  warm  bath  and  fiee  perspiration  in  the  effort 
to  eliminate  by  the  skin  the  necessary  quantity  of  urea.  To  this,  mild 
purgation  may  be  added.  When  the  cyst  is  large  enough  to  interfere 
with  the  comfort  or  to  threaten  the  life  of  the  patient,  it  should  be 
aspirated  or  cut  down  iipon  and  drained  by  incision,  or  completely  re- 
moved. In  introducing  the  aspirator-needle,  the  most  prominent  part 
of  the  protrusion  near  the  last  rib  should  be  punctured.  If  the  con- 
dition of  the  patient  will  permit,  preference  should  be  given  to  incision 
and  free  drainage  of  the  cyst.  If  the  cyst-wall  has  not  adhered  firmly 
to  the  surrounding  tissues,  the  dissection  should  be  carried  down  to  the 
cyst  and  the  wound  packed  with  sublimate  gauze  for  a  day  or  two  until 
adhesions  have  taken  place,  after  which  the  contents  may  be  evacuated. 

Renal  Calculus. — Stone  in  the  kidney  may  be  formed  by  an  aggre- 
gation of  urinary  crystals  in  the  tubules,  calices,  or  pelvis  of  this  organ. 
To  the  composition  of  these  bodies  epithelia,  mucous  and  other  organic 
substances  contribute.  Although  chiefly  composed  of  uric  acid  in  va- 
rious combinations,  and  oxalic  acid  in  combination  with  lime,  renal  cal- 
culi may  be  as  variable  as  those  to  be  considered  in  connection  with  dis- 
eases of  the  bladder. 

The  symptoms  of  stone  in  the  pelvis  or  the  kidney  are  referable  to 
the  degree  of  inflammation  (iDyelitis)  caused  by  its  presence,  and  to  the 
interference  with  the  escape  of  urine  into  the  ureter.  The  condition  of 
pyelitis  is  in  great  part  determined  by  the  shape  and  composition  of  the 
calculus. 

A  mulberry  calculus  (oxalate  of  lime)  produces  here,  as  in  the  blad- 
der, a  more  acute  and  therefore  more  perceptible  inflammatory  process 
than  the  smooth  uric-acid  or  phosphatic  stones.  Stones  with  smooth 
surfaces  and  of  slow  formation  may  remain  months  in  the  pelvis  with- 
out causing  a  disturbance  sufficient  to  attract  the  attention  of  the  patient 


GEXITO-URIXART  ORGANS.  623 

or  physician.  This  is  especially  true  if  the  body  does  not  drop  into  the 
opening  of  the  ureter.  Sudden  occlusion  of  this  tube  produces  symp- 
toms of  general  disturbance.  If  the  stone  is  small  and  smooth,  it  may 
pass  into  the  outlet  and  find  its  way,  by  gravity  and  the  pressure  of 
urine  from  behind,  into  the  bladder  without  attracting  the  attention  of 
the  patient.  When  a  rough  stone,  or  one  large  enough  to  distend  the 
tube  enters  the  ureter,  symptoms  of  a  more  than  usually  painful  nature 
appear.  The  pain  is  usually  referred  to  the  neighborhood  of  the  im- 
pacted substance  ;  it  is  violent  to  a  degi'ee  rarely  experienced  in  any 
other  affection.  It  may  be  spasmodic  or  constant.  In  males  the  testicle 
of  the  affected  side  is  drawn  up  toward  the  external  ring,  and  not  infre- 
quently the  pain  is  felt  in  this  organ,  in  the  scrotum,  penis,  and  down 
the  thigh  and  leg.  Vomiting  may  be  present,  and  constipation  is  the 
rule.  Suppression  of  urine  foUows  in  a  small  proportion  of  cases,  and, 
on  the  other  hand,  in  some  instances  the  quantity  excreted  is  greater 
than  nonnal.  In  the  majority  of  cases  red  blood-disks  may  be  found  in 
the  urine.  The  duration  of  the  attack  varies  from  a  few  hours  to  days. 
When  the  stone  escapes  into  the  bladder,  the  relief  is  as  sudden  as  the 
attack.     In  rare  iastances  it  becomes  hopelessly  impacted. 

The  treatment  of  renal  calculus  is  practically  palliative.  The  diath- 
esis of  the  individual  must  be  corrected.  The  diet,  mode  of  life,  and 
surroundings  which  produce  one  stone  in  the  kidney  will  cause  the  same 
lesion  indefinitely.  The  character  of  the  urine  must  be  carefully  studied 
and  an  effort  made  to  dissolve  the  concretion  in  the  pelvis.  The  object 
of  this  plaji  is  to  carry  in  contact  with  the  stone,  through  the  agency  of 
the  blood,  certain  reagents  which  are  supposed  to  effect  the  dissolution 
of  these  concretions.  The  citrate  of  potash,  in  doses  of  from  grs.  xx- 
XXX,  is  a  favorite  remedy.  It  is  especially  commended  in  the  uric-acid 
calculus,  and  should  be  given  several  times  a  day,  freely  diluted  with 
water  or  flax-seed  tea,  and  continued  for  several  months.  In  phos- 
phatic  calculi  the  benzoate  of  ammonia,  in  doses  of  grs.  v-xx,  should 
be  employed.  When  the  persistence  of  symptoms  points  to  the  forma- 
tion and  enlargement  of  renal  calculus,  nephrotomy  is  indicated. 

When  renal  colic  occurs,  the  chief  indication  is  to  alleviate  pain,  and 
for  this  purpose  the  hypodennic  use  of  morphia  is  most  efBcient.  Ether 
narcosis  may  also  be  employed  where  morphia  or  opium  is  contra-indi- 
cated. Pain  is  not  only  allayed  by  this  means,  but  the  relaxation  of 
the  muscular  elements  of  the  ureters  secured  and  the  passage  of  the 
calculus  greatly  facilitated.  In  case  the  calculus  becomes  permanently 
lodged  in  the  ureter,  the  operation  of  nephrectomy  may  be  necessitated. 
This  procedure  will  be  described  hereafter. 

Cysts. — In  addition  to  the  form  of  cyst  which  is  caused  by  obstruction 
beyond  the  pelvis  of  the  kidney,  there  may  exist  smaller  cysts  within  the 
substance  of  this  organ  resulting  from  occlusion  of  one  or  more  of  the 
tubules.  These  cysts  are  usually  small.  When  the  obstruction  occurs 
near  the  apex  of  the  pyramid,  the  entire  tubular  structure  of  that  pyra- 
mid may  be  destroyed.  Hydatid  cysts,  due  to  the  lodgment  of  the  ova 
of  the  tcBnia  ecMnococcus,  are  occasionally  met  with  in  the  kidney. 


624  A  TEXT-BOOK  ON   SURGEKY. 

The  symptoms  of  renal  cyst  are  usually  obscure  until  the  tumor  be- 
comes large  enough  to  exercise  pressure  on  neighboring  viscera  or  to 
appear  as  a  swelling  in  the  lumbar  region.  Fluctuation  or  aspiration 
will  determine  the  cystic  character  of  the  tumor. 

The  treatment  of  renal  cysts  is  conservative  so  long  as  life  is  not 
endangered  by  the  pressure  of  the  tumor.  The  danger  of  rupture  into 
the  peritonseum  is  not  to  be  overlooked  as  a  j)ossible  and  fatal  accident. 

Opening  into  the  retroperitoneal  space  is  also  an  exceedingly  danger- 
ous complication.  It  may  be  put  down  as  a  safe  rule  of  practice  that 
when  a  tumor  of  the  kidney  becomes  large  enough  to  be  appreciated  by 
palpation  or  inspection,  and  is  proved  to  be  cystic  in  character,  the  con- 
tents should  be  evacuated  by  incision. 

Carcinoma  may  be  primary  in  the  kidney  or  secondary  by  extension 
from  a  contiguous  organ,  or  by  metastasis.  In  primary  cancer  only  one 
organ  is  affected.  When  the  disease  extends  from  the  bladder  it  is  likely 
to  involve  both  organs,  and  the  same  is  true  of  secondary  deposits  by 
metastasis.  The  adenoid  or  encephaloid  variety  is  most  frequently  met 
with.  All  ages  are  liable  to  this  disease.  The  tumefaction  is  often  very 
rapid,  and  may  reach  enormous  proportions,  death  resulting  from  asthe- 
nia due  to  the  mechanical  presence  of  the  mass,  as  well  as  to  the  general 
dissemination  of  the  disease. 

The  diagnosis  of  cancer  of  the  kidney  will  depend  upon  the  appre- 
ciation of  the  tumor  and  a  careful  study  of  the  history  of  the  case.  The 
differentiation  between  the  solid  and  cystic  tumors,  which  has  already 
been  given,  will  eliminate  hydatids  or  obstruction  to  the  outflow  of 
urine  and  cystic  degeneration.  The  recognition  of  the  cancer  must  de- 
pend upon  the  presence  of  the  peculiar  cachexia.  The  treatment  should 
be  directed  to  the  alleviation  of  pain.  The  removal  of  the  organ  is 
scarcely  justifiable,  since  metastasis  will  in  great  probability  have  oc- 
curred before  the  character  of  the  disease  can  be  recognized. 

Sarcoma  of  the  kidney  is  a  rare  form  of  disease,  and  this  is  espe- 
cially true  of  primary  sarcoma.  The  presence  of  this  neoplasm,  danger- 
ous in  any  portion  of  the  economy,  is  especially  so  in  the  kidney,  where 
its  deep  location  renders  an  early  diagnosis  almost  impossible. 

Adenoma,  lympJiadenomci,  and  papilloma  may  also  be  found  in  this 
organ.  Adenoma  and  papilloma  can  scarcely  be  recognized.  The  same 
may  be  said  of  lymphadenoma,  as  far  as  the  kidney  proper  is  concerned, 
for  it  can  scarcely  be  recognized  during  life,  the  diagnosis  depending 
upon  the  general  condition  of  lymphadenoma  and  leucaemia.  Angio- 
mata  of  the  cavernous  variety  has  been  noted  in  the  kidney  in  rare  in- 
stances. Rhabdomyoma  of  the  kidney,  an  unusual  form  of  neoplasm, 
which  has  lately  been  described,  may  be  also  mentioned  here.  It  is  sup- 
posed to  be  congenital,  and  is  composed  of  striped  muscle-tissue. 

Suppression  of  Urine. — Not  infrequently  after  a  surgical  operation, 
especially  upon  the  rectum  and  genito-urinary  organs,  the  function  of 
the  kidneys  is  partially  or  completely  suspended.  Suppression  may  also 
follow  an  injury  to  any  portion  of  the  body,  or  any  violent  emotion.  It 
may  occur  in  patients  with  healthy  kidneys,  but  is  especially  apt  to  be 


GENITO-URINARY   ORGANS.  625 

met  with  in  individuals  who  suffer  from  acute  or  chronic  nephritis.  It 
is  always  fraught  with  great  danger,  demanding  immediate  relief,  in  the 
hope  either  of  restoring  the  function  of  these  organs  at  once,  or  of  in- 
ducing a  compensatory  elimination  of  urea  and  the  products  of  tissue- 
waste  by  the  skin  and  mucous  surfaces. 

The  symptoms  are  unuatui-al  dryness  and  heat  of  the  skin ;  high 
febrile  movement ;  quick,  distended  pulse  ;  at  times,  headache  ;  pain  in 
the  lumbar  region  ;  delirium,  coma,  and  convulsions.  These  graver  symp- 
toms are  usually  observed  in  the  latter  stages  of  complete  suppression. 
If  not  relieved,  the  exhalations  from  the  skin  and  air-passages  have  the 
odor  of  urine.  Lastly,  though  not  least  in  importance  in  diagnosis,  is 
the  absence  of  urine  determined  by  catheterization. 

In  all  surgical  operations  the  condition  of  the  kidneys  can  not  be  too 
closely  studied  or  too  carefully  watched.  WhUe  nephritis,  pyelitis,  or 
any  kidney  lesion  should  not  deter  the  surgeon  from  a  necessary  opera- 
tion, it  should  render  his  prognosis  more  guarded,  and  thus  relieve  him 
in  great  part  from  the  responsibility  of  failure. 

The  immediate  indication  in  the  treatment  of  suppression  is  chiefly  to 
excite  diaphoresis.  Opium  is  a  valuable  remedy,  for  it  not  only  relieves 
pain,  which  is  at  times  intense,  but  excites  perspiration.  The  steam- 
bath  is  also  very  useful,  and  should  be  given  in  the  recumbent  posture. 
A  ready  method  is  to  generate  the  vapor  in  a  tea-kettle  and  lead  the  steam 
under  the  bedclothes  by  a  piece  of  tubing.  Or  hot  water  may  be  poured 
into  a  large  vessel  placed  under  the  blanket  which  is  next  to  the  patient. 

Next  to  diaphoresis,  mild  purgation  is  advisable,  although  it  should 
not  be  carried  to  the  extent  of  exhaustion.  The  cautious  employment 
of  the  muriate  of  pilocarpin  is  justifiable  in  extreme  cases.  The  depress- 
ing effect  of  this  drug  upon  the  heart  should  not  be  overlooked.  The 
dose  should  not  be  more  than  one  twelfth  of  a  grain,  hypodermically,  and 
repeated  in  half  an  hour  if  necessary.  The  hot-bath  should  be  admin- 
istered at  the  same  time.  If  there  are  no  symptoms  of  acute  nephritis, 
and  if  the  kidneys  do  not  resume  their  function  within  a  few  hours,  diu- 
retics should  be  given.  A  decoction  of  scoparius,  or  extract  of  buchu, 
will  be  found  useful. 

Operation  for  exploring  the  Kidney  and  for  its  Removal. — When 
the  kidney  becomes  the  seat  of  any  disease  which  is  progressive,  and 
which,  in  the  opinion  of  the  surgeon,  will  immediately  or  remotely  en- 
danger the  life  of  the  patient,  operative  interference  is  indicated. 

Exploration  toith  the  Aspirator- Needle. — In  operations  upon  these 
organs  the  following  anatomical  points  should  be  borne  in  mind :  By 
reason  of  the  large  si^e  of  the  liver,  the  right  kidney  occujoies  a  position 
about  one  inch  lower  than  the  left ;  anteriorly  it  is  partially  overlapped 
by  this  organ  ;  its  lower  end  is  a  little  below  the  level  of  the  umbilicus  ; 
the  ascending  colon  is  in  front.  The  left  kidney  has  in  front  of  it  the 
descending  colon  ;  the  spleen  at  times  may  overlap  its  upper  end ;  its 
lower  end  is  a  little  above  the  level  of  the  umbilicus. 

In  exploring  a  diseased  kidney  percussion  will  serve  to  locate  the 
colon  so  that  it  may  be  avoided.     If  fluctuation  is  present,  the  point  at 

40 


626  A  TEXT-BOOK   ON  SURGERY. 

wMcli  it  is  most  superficial  should  be  selected  for  puncture.  In  general, 
the  organ  will  be  reached  most  safely  three  and  a  half  inches  from  the 
spines  of  the  vertebree. 

If  an  exploratory  aspiration  demonstrates  the  presence  of  fluid  (other 
than  blood),  an  incision  should  follow,  for  the  reason  that  the  escape  of 
liquid  into  the  retroperitoneal  space,  or  into  the  peritonseum,  is  a  danger 
to  be  avoided  by  incision  and  drainage  through  the  lumbar  region. 

Nephrotomy  is  performed  by  making  an  incision  from  the  last  rib  to 
near  the  iliac  crest,  parallel  to  and  three  and  a  half  inches  from  the  ver- 
tebral spines.  Dividing  the  integument,  fasciae,  and  fat,  the  edge  of  the 
quadratus  lumborum  is  sought,  and  the  aponeurotic  extension  of  the 
transversalis  muscle  divided,  when  the  finger  can  be  passed  into  the  re- 
troperitoneal space  behind  the  colon  and  directly  upon  the  kidney.  All 
haemorrhage  should  be  arrested  as  it  occurs.  By  drawing  the  edges  of 
the  wound  wide  apart  with  flat  retractors,  the  fatty  capsule  may  be  sepa- 
rated with  the  fingers  or  handle  of  the  scalpel,  and  the  exact  condition 
of  the  organ  determined.  If  an  abscess  be  discovered,  or  any  lesion  de- 
manding incision  and  drainage,  this  should  be  done. 

If  the  pelvis  is  blocked  with  stone,  or  if  there  is  a  calculus  in  the 
kidney,  which  may  be  determined  by  digital  exploration,  it  should  be 
removed  by  incision.  The  operation  is  known  as  nephrolithotomy.  The 
incision  should  be  left  open  and  drained.  When  the  kidney  has  suffered 
displacement,  and  is  causing  distress  by  dragging  upon  its  vessels,  if  it 
is  otherwise  normal  it  should  be  carried  as  nearly  into  its  former  posi- 
tion as  possible  and  its  capsule  stitched  to  the  edges  of  the  ^vound 
through  the  abdominal  walls.  Catgut  sutures  of  large  size  should  be 
used,  and  these  passed  well  into  the  fatty  capsule  which  surrounds  this 
organ.  The  fibrous  capsule  proper  of  the  kidney  should  not  be  perfo- 
rated by  the  needle.  The  patient  must  be  kept  in  the  dorsal  decubitus 
until  adhesions  have  been  formed  sufficient  to  hold  the  organ  in  place. 

Nephrectoviy,  or  removal  of  the  kidney,  has  been  successfully  per- 
formed so  often  of  late  years  that  its  advisability  in  certain  diseases  of 
this  organ  is  unquestioned.  Before  undertaking  this  operation  the  pre- 
caution should  be  observed  of  determining  not  only  the  jjresence  of  a 
second  organ,  but  its  condition.  A  fatal  result  has  followed  the  removal 
.of  a  single  or  "horse-shoe"  kidney.  It  is  equally  important  to  deter- 
mine, if  possible,  whether  the  opposite  organ  is  capable  of  carrying  on 
the  necessary  excretion  of  urine.  The  presence  of  a  second  organ  may 
be  made  out  by  palpation.  That  it  is  performing  its  function  satisfac- 
torily may  be  determined  by  a  quantitative  and  qualitative  analysis  of 
the  urine  discharged.  The  quantity  of  the  fluid  and  urea  eliminated 
should  approximate  the  normal.  If  albumen  is  present,  and  there  is  no 
pus  in  the  urine,  the  gravity  of  the  prognosis  is  increased.  Any  symp- 
toms of  uraemia  should  contraindicate  the  operation. 

The  organ  is  reached  by  the  same  incision  given  for  nephrotomy. 
When  necessary  to  secure  the  vessels  at  the  hilus,  the  wound  may  be 
enlarged  by  a  limited  transverse  incision.  All  bleeding  should  be  ar- 
rested as  it  occurs.     When  the  fatty  capsule  is  reached,  it  should  be 


GENITO-URINARY   ORGANS. 


627 


scratched  throiigli  with  the  finger-nail,  or  torn  between  two  forceps.  As 
soon  as  the  hilus  is  exposed,  the  vessels  should  be  tied  with  double- 
strong  silk  threads,  divided  between  the  ligatures,  and  the  organ  re- 
moved. When  the  organ  is  greatly  enlarged,  it  will  be  advisable  to 
throw  a  temporary  elastic  ligature  around  the  entire  pedicle,  remove  the 
kidney  and  then  secure  the  vessels  separately.  The  wound  should  be 
irrigated  with  sublimate  solution,  drainage-tubes  inserted,  and  an  anti- 
septic dressing  applied. 

In  nejjhrectomy  for  displacement  of  the  kidney  {floating  Jcidney), 
the  operation  should  be  made  through  the  abdominal  wall  directly  over 
the  recognized  position  of  the  organ.  The  intestines  should  be  dis- 
placed laterally  and  the  posterior  layer  of  the  peritonaeum  torn  open 
just  enough  to  permit  the  removal  of  this  mass.  When  the  displaced 
organ  is  not  diseased,  and  is  near  its  original  position,  an  effort  should 
be  made  to  secure  it  in  its  prop- 
er place  by  stitching  the  capsule 
to  the  lumbar  fascia  with  catgut 
sutures. 

The  Ureters.  —  The  diseases 
which  affect  the  ureters  do  not 
demand  especial  consideration. 
The  inflammatory  processes  are 
those  which  extend  downward 
from  the  pelvis  of  the  kidney  or 
upward  from  the  bladder.  The 
same  may  be  said  of  neoplasms. 
Partial  or  complete  occlusion 
from  pressure  within  the  canal, 
as  from  a  migrating  or  impacted 
calculus,  or  by  pressure  from  a 
tumor  from  without  (as  by  an 
aneurism  or  neoplasm),  may  de- 
mand surgical  interference. 

Bladder.  —  Among  the  con- 
genital lesions  of  the  bladder 
to  which  the  attention  of  the 
surgeon  is  called,  exstrophy  is 
most  frequently  observed.  More 
rarely  there  are  several  sacs, 
each  with  a  ^^reter,  or  there  may 
be  a  central  septum  dividing  the 
bladder  into  two  chambers  of 
about  equal  size,  with  a  ureter 
emptying  into  each.  The  blad- 
der is  at  times  absent,  the  ure- 
ters opening  into  the  alimentary 
canal,  vagina,  or  perinseum,  or  into  the  pelvis,  at  a  point  corresponding 
to  the  normal  position  of  the  bladder. 


Fi(     5P4 
Exstrophy  ot  tlic  bl.iddti      bo  calkd  hermaphrodite. 


628 


A  TEXT-BOOK   ON   SURGERY. 


MxstropTiy,  or  eversion  of  the  bladder  (Fig.  564),  is  almost  always 
met  with  in  males.  It  is  caused  by  a  failure  of  development  in  the 
anterior  pelvic  and  abdominal  regions.  The  integument,  muscles,  pubic 
bones,  and  anterior  part  of  the  bladder-wall  are  missing.  Through  this 
gap  the  part  of  the  bladder  which  may  be  present  is  protruded,  as  a 
mass  of  variable  size  (depending  upon  the  extent  of  the  deformity  and 
upon  the  position  of  the  patient),  from  one  inch  up  to  three  or  iowv 
inches  in  diameter.  In  the  erect  posture  it  is  always  largest,  being 
pushed  out  by  the  descent  of  the  abdominal  viscera,  and  complicated 
by  hernia  of  the  intestine.  The  mucoxis  membrane,  which  covers  the 
mass,  is  in  appearance  not  unlike  a  recent  non-strangulated  prolapsus 
ani.  The  orifices  of  the  ureters  may  be  found  opening  at  some  point 
on  the  lower  portion  of  the  protrusion,  and  are  often  considerably  di- 
lated. In  all  cases  of  exstrophy  the  genital  apparatus  is  rudimentary. 
The  penis  is  wholly  or  in  great  part  wanting.  The  urethra  may  be  seen 
as  a  simple  groove,  into  which  the  seminal  ducts  enter.  The  sci'otum, 
at  times  entirely  absent,  may  in  other  cases  be  present,  lodging  the  tes- 
ticles, or  it  may  be  bind,  with  one  organ  in  each  sac,  or  entirely  missing, 
the  testes  remaining  in  the  abdomen,  or  lodged  in  the  groin  or  thigh. 

The  degree  of  exstrophy  varies  in  proportion  to  the  extent  of  the 
malformation.     In  the  more  favorable  cases  the  pubic  bones  are  almost 
united  at  the  symphysis,  and  the  protrusion 
consequently  small. 

In  females  the  genital  organs  are  also  rudi- 
mentary. The  clitoris,  nymphse,  vagina,  and 
uterus  may  be  absent  or  displaced,  and  only 
partially  developed.  The  general  apj^earances 
of  the  tumor  ai'e  the  same  in  both  sexes. 

Exstrophy  of  the  bladder,  even  in  a  mild 
form,  is  a  source  of  great  annoyance. 

The  treatment  is  chiefly  palliative,  and  con- 
sists in  an  apparatus  to  drain  the  urine  off  and 
prevent  excoriations.  A  suitable  instrument  is 
shown  in  Fig.  564  a.  The  oi^erative  treatment 
consists  in  an  effort  to  cover  in  the  protruding 
mass  by  integument  borrowed  from  the  imme- 
diate vicinity  of  the  tumor. 
Fjg.  564  a.  No  definite  line  of  procedure  can  be  ad- 

vised. The  skin  may  be  turned  from  the  abdo- 
men, thighs,  and  peringeum.  The  operation  is  not  without  danger  to  life, 
and,  when  not  fatal,  frequently  fails  to  benefit  the  patient.  The  chief 
difficulty  lies  in  protecting  the  flaps  from  contact  with  the  urine.  To  ob- 
viate this,  the  procedure  of  Levis  more  nearly  meets  the  indications.  It 
consists  in  establishing  a  false  urethra  from  that  portion  of  the  partly  de- 
veloped bladder  near  the  orifices  of  the  ureters  through  to  the  peringeum. 
A  large  and  long  needle,  armed  with  a  good-sized  thread  or  wire,  is 
carried  through  the  wall  of  the  bladder,  just  at  the  openings  of  the  ure- 
ters, and  brought  out  in  the  peringeum,  about  an  inch  in  front  of  the 


GEXITO-UEIXARY   ORGAXS.  629 

anus.  The  vrii-e  is  allowed  to  remain  as  a  seton,  and  through  the  tistnla 
thns  established  the  nrine  begins  to  flow.  The  false  urethra  is  enlarged, 
by  gradual  dilatation  with  bougies,  until  it  is  of  sufficient  size  to  carry 
off  all  the  urine.  T\Tien  this  is  accomplished,  the  second  stage  of  the 
operation  consists  in  covering  the  exstrophy  vrith.  integument  turned  over 
from  the  immediate  neighborhood  of  the  deformity.  In  males,  one  in- 
cision may  be  carried  fi'om  near  the  center  of  Poupart's  ligament,  curving 
do^vnward  along  the  inner  side  of  the  thigh,  across  the  scrotum  or  peri- 
neum, as  the  case  may  demand,  and  terminating  at  a  corresponding  point 
upon  the  opposite  side.  This  flap  is  dissected  up  toward  the  edges  of  the 
exstrophy,  leaving  a  line  of  attachment  sufficient  to  supply  nutrition  to 
it.  A  second  flap  is  turned  down  from  the  abdomen,  and  the  two  are 
sewed  together,  the  raw  surfaces  being  now  external,  while  the  epidemiis 
is  internal,  and  in  contact  with  the  mucous  surface  of  the  deformed  blad- 
der. If  the  penis  is  sufficiently  developed,  a  hole  should  be  cut  in  the 
lower  flap  and  this  organ  drawn  through.  The  outer  raw  surface  may  be 
left  alone  to  cicatrize,  although  it  should  be  covered  over  at  a  subsequent 
operation,  if  there  is  enough  integument  left  to  borrow  from.  If  not,  the 
granulating  surface  may  be  covered  with  grafts. 

In  females  the  same  method  of  operation  may  be  used,  modif  j"ing  the 
flap  to  suit  the  deformity,  and  to  preserve  as  much  of  the  functions  of  the 
genital  organs  as  possible. 

Hernia  Yesicce,  or  Cystocele. — Hernia  of  the  bladder  is  a  very  rare 
accident.  It  is  more  apt  to  occur  in  connection  with  a  perforating  wound 
of  the  pelvis  or  supra-pubic  region.  Idiopathic  cystocele  occurs  chiefly 
in  the  aged,  and  in  those  who  have  atony  of  the  walls  of  this  organ  from 
habitual  retention  of  urine,  and,  at  the  same  time,  some  form  of  intestinal 
hernia.  The  bladder  becomes  top-heavy  and  flabby,  and  readily  pro- 
lapses into  the  patulous  inguinal  or  femoral  canal,  as  the  case  may  be. 

The  diagnosis  is  evident  if  the  tumor  diminishes  with  the  evacuation 
of  the  organ  by  catheterization,  and  becomes  distended  by  injection 
through  the  urethra.  If  it  should  become  strangulated.  asi:)tration  with 
the  finest  needle,  and  microscopic  examinarion  of  the  fluid  withdrawn, 
will  confirm  the  diagnosis  of  cystocele. 

Treatment. — Hernia  of  the  bladder  should  be  rediiced  by  taxis,  and 
prevented  fi-om  recurrence  by  a  truss.  If  it  should  become  strangulated, 
and  gangrene  occur,  an  incision  should  be  made,  and  the  wound  treated 
antiseptically.  A  fistula  resulting  from  this  j)ractice  will  close  by  granu- 
lation, or  can  be  cured  by  a  subsequent  operation. 

Wounds. — A  solution  of  continuity  in.  the  walls  of  the  bladder  may 
be  caused  by  penetration  from  without,  as  in  the  case  of  a  shot-  or  stab- 
wound,  by  rupture  from  over-distention.  by  violent  concussion,  or  by 
direct  injury  from  displaced  fragments  of  bone  in  fractures  of  the  pel- 
vis. Penetrating  wounds  of  the  bladder  are  rare,  not  only  on  account  of 
the  protection  afforded  by  the  pelvic  bones,  but  because  its  usual  condi- 
tion is  that  of  only  partial  distention.  This  is  especially  true  of  wounds 
received  in  military  practice,  since  soldiers  going  into  action  almost  in- 
variably empty  this  organ. 


630  A  TEXT-BOOK   ON   SURGERY. 

The  diagnosis  of  a  penetrating  wound  of  the  bladder  depends  upon 
the  escape  of  urine  through  the  opening,  or  the  sudden  appearance  of 
blood  or  particles  of  clothing,  or  other  foreign  matter,  in  the  urine. 
Shock  is  usually  profound.  Hsemorrhage  is  not  severe,  unless  some  of 
the  iliac  arteries  or  their  larger  branches  are  involved. 

The  prognosis  is  always  grave,  though  not  necessarily  fatal.  The 
immediate  danger  is  from  haemorrhage  and  shock.  Peritonitis  is  in- 
evitable if  the  wound  is  above  the  attachment  of  this  membrane  to 
the  bladder.  If  below  this  line,  the  infiltration  will  lead  to  pelvic 
cellulitis. 

The  indications  in  treatment  are  to  arrest  haemorrhage,  and  to  prevent 
infiltration  and  sepsis  by  free  incision  and  drainage.  When  the  large 
vessels  of  the  pelvis  are  wounded,  an  effort  should  be  made  to  arrest  the 
bleeding  by  compression  and  the  ligature. 

If  extravasation  of  urine  into  the  cavity  of  the  peritonaeum  has  taken 
place,  the  abdomen  should  be  opened  and  thoroughly  irrigated  with  warm 
Thiersch's  solution.  If  this  is  not  convenient,  warm  sublimate  solution, 
1  to  20000,  may  be  employed,  or  warm  water.  The  entire  cavity  should 
be  filled  with  the  fluid,  and  should  afterward  be  thoroughly  dried  out 
with  clean,  soft  sponges.  In  a  case  which  came  under  my  observation, 
the  bladder  was  wounded  at  its  summit,  and  urine  escaped  freely  into  the 
cavity  of  the  peritonaeum.  The  abdomen  was  flooded  with  l-to-20000 
sublimate  solution,  and  carefully  sponged  out.  The  patient  recovered 
without  a  symptom  of  peritonitis.  In  this  case  the  edges  of  the  incision 
in  the  linea  alba  were  held  open  by  retractors,  and  the  warm  solution 
poured  in  from  a  pitcher. 

If  the  wound  in  the  bladder  is  small,  and  is  so  situated  that  its 
edges  can  be  stitched  together,  it  should  be  closed  at  once  by  fine  silk 
or  catgut  suture,  as  directed  in  supra-pubic  cystotomy.  Under  other 
conditions  the  T  rubber  drainage-tube  should  be  introduced  through 
the  wound  into  the  bladder,  and  the  patient  jjlaced  in  the  lateral  po- 
sition to  facilitate  drainage.  It  is  of  vital  importance  that  the  urine 
be  not  allowed  to  collect  and  distend  the  bladder,  and  thus  cause  in- 
filtration. 

When  the  opening  into  the  bladder  is  intra-peritoneal,  if  the  wound 
can  be  thoroughly  closed  by  sutures  this  should  be  done  at  once,  and,  in 
order  to  secure  the  immediate  evacuation  of  all  urine,  a  soft  catheter 
should  be  fastened  in  through  the  urethra,  or,  better  still,  through  the 
free  wound  of  a  perineal  cystotomy.  If  the  opening  can  not  be  safely 
closed,  the  edges  of  the  wound  in  the  bladder  should  be  securely  stitched 
by  silk  sutures  to  the  margins  of  the  wound  in  the  integument  of  the 
abdominal  walls,  and  the  thorough  emptying  of  the  organ  insured  as 
above. 

Rupture  of  the  Bladder.— This  accident  is  much  more  frequent  witli^ 
men  than  women.  When  occurring  in  females  it  is  usually  during 
parturition,  or  from  continuous  pressure  of  this  organ  by  uterine  or 
ovarian  tumors.  Obstruction  of  the  urethra  is  the  chief  cause  of  idio- 
pathic rupture.     In  enlarged  prostate,  or  close  stricture  of  long  stand- 


GENITO-URINARY  ORGANS. 


631 


ing,  the  bladder  becomes  gradually  accustomed  to  the  presence  of  an 
abnormal  quantity  of  urine,  its  walls  become  thin  and  weak  under  the 
process  of  dUatation,  until,  after  a  sudden  excessive  accumulation,  rupt- 
ure occurs.  In  rare  instances  the  bladder-wall  is  weakened  by  ulceration 
to  such  an  extent  that  it  gives 
way.  Rupture  of  a  diseased  or 
normal  bladder  may  follow  a 
violent  concussion,  especially  if 
the  organ  be  fully  or  partially 
distended,  and  the  blow  inflict- 
ed over  the  lower  abdominal 
region.  Fracture  of  the  pelvis 
is  not  infrequently  complicated 
with  this  grave  accident.  Frag- 
ments of  bone  may  be  driven 
through  the  walls  of  the  blad- 
der, or  the  rupture  may  occur 
from  compression  alone. 

The  location  of  the  rupture 
is,  fortunately;  in  the  majority 
of  cases,  through  portions  of 
the  organ  not  covered  by  peri- 
tonaeum. The  anterior-inferior 
or  sub-pubic  portion  and  the 
neighborhood  of  the  trigonum 
vesicae  are  most  apt  to  give  way. 

The  symptoms  of  rupture  are 
not  always  j^rominent.  When 
violence  may  be  eliminated,  there 
is  usually  a  history  of  over- 
distention,  a  desii'e  to  urinate, 
a  feeling  as  if  something  had 
given  way,  with  partial  or  com- 
plete relief  from  the  pressure  within  the  bladder.  When  the  rupture  is 
extra-peritoneal,  the  signs  of  infiltration  in  the  perinseum  and  perirectal 
tissues  are  easily  recognized.  Direct  external  palpation,  or  the  intro- 
duction of  the  finger  into  the  rectum,  will  recognize  the  doughy  condi- 
tion of  the  tissues.  If  the  hypodermic  needle  is  introduced,  a  few  drops 
of  bloody  urine  may  be  withdrawn.  When  the  rupture  is  so  situated 
that  urine  escapes  into  the  peritoaeal  cavity,  the  earlier  signs  are  shock, 
of  a  severe  type,  with  dullness  on  percussion  in  the  hypogastric  and 
inguinal  regions.  In  confirming  a  diagnosis  based  upon  any  of  the 
foregoing  symptoms,  an  examination  of  the  bladder  by  the  sound  or 
catheter  is  essential.  The  passage  of  this  instrument  through  an  open- 
ing, so  that  it  may  be  felt  beneath  the  abdominal  walls,  is  a  demonstra- 
tion of  rupture.  The  passage  of  a  small  amount  of  bloody  urine,  with 
or  without  the  catheter,  is  a  suspicious  sign,  and  if  this  small  quantity  is 
passed  with  each  respiratory  act  the  evidence  is  almost  convincing.     The 


Fig.  56.3.— Xlie  relations 
der  when  distended. 


i|-  tlu 

(After  Tarnier.) 


t"  the  blad- 
1,  The  situ- 


ation of  the  trigonum  vesicse.     2,  Prostatic  urethra. 


632  A   TEXT-BOOK   ON   SURGEKY. 

exploration  of  the  pelvic  region  with  the  aspirator-needle  will  determine 
the  presence  of  nrine  in  the  tissues  outside  of  the  bladder. 

Treatment. — In  extra-peritoneal  rupture  immediate  and  fi'ee  incision 
should  be  made  into  the  infiltrated  zone,  and,  while  this  is  being  done 
under  ether,  the  bladder  should  be  incised  as  in  lateral  lithotomy,  or  by 
the  supra-pubic  method,  as  may  be  indicated.  The  free  escape  of  urine 
through  this  incision  arrests  infiltration  and  keeps  the  bladder  in  repose, 
thus  facilitating  a  closure  of  the  rupture. 

The  treatment  of  rupture  of  the  bladder  into  the  cavity  of  the  peri- 
tonseum  has  just  been  given  in  penetrating  wounds  of  this  organ. 

The  comparatively  slight  risk  involved  in  an  exploratory  incision 
through  the  linea  alba  into  the  cavity  of  the  peritoneum  should  encour- 
age the  surgeon,  even  in  cases  in  which  there  may  be  some  doubt  as  to 
the  correctness  of  the  diagnosis,  to  perform  this  operation.  The  knowl- 
edge that  death  has  so  far  resulted  in  every  case  of  intra-peritoneal  rupt- 
iire  of  the  bladder  in  which  surgical  interference  has  not  been  made, 
adds  an  additional  justification  to  the  exploration  of  this  cavity. 

Cystitis. — Inflammation  of  the  bladder  is  one  of  the  most  common 
surgical  diseases.  It  may  be  acute  or  chronic.  In  the  majority  of  in- 
stances only  the  mucous  membrane  of  the  neck  and  floor  of  this  organ 
is  affected.  Less  frequently  the  entire  mucous  lining  is  attacked.  In 
extreme  cases  the  inflammation  attacks  the  muscular  walls,  and  spreads 
to  the  peritonaeum  and  pelvic  fascia.  An  acute  cystitis  ending  in  rapid 
recovery  rarely  leads  to  hypertrophy  or  thickening  of  the  walls  of  the 
bladder.  In  chronic  cystitis  thickening  is  the  rule.  Hypertrophy  of 
the  bladder  may  be  true  or  false.  In  true  hypertrophy  the  thickening 
is  caused  by  an  increase  of  the  muscular  elements  of  the  organ  ;  in  false 
hypertrophy  it  is  due  to  new-formed  connective  tissue,  which  has  in 
great  part  taken  the  place  of  the  muscular  fibers.  When  the  walls  are 
thickened  and  the  cavity  is  smaller  than  normal,  the  hypertrophy  is 
called  concentric;  when  the  cavity  is  increased  and  the  walls  thick- 
ened, eccentric. 

Cystitis  may  be  caused  by  a  blow  upon  the  lower  portion  of  the  ab- 
domen, or  in  the  perineal  or  ischiorectal  region,  or  by  the  direct  con- 
tact of  an  instrument  or  any  liquid  or  solid  substance  canied  into  the 
cavity  of  the  bladder.  Inflammation  of  this  organ  always  exists  with 
calculus,  and  almost  always  with  chronic  hypertrophy  of  the  prostate. 
It  may  become  involved  by  extension  of  an  inflammatory  process  from 
the  urethra  or  prostate,  from  the  vagina,  the  kidneys,  or  ureters.  Cer- 
tain abnormal  conditions  of  the  urine,  excessive  indulgence  in  drinking 
or  eating,  the  pressure  of  another  organ  or  a  neoplasm,  or  the  presence  of 
a  new  formation  or  parasites  within  the  cavity  or  in  the  walls  of  this  vis- 
cus  (Bilharzia  hcematobia),  etc.,  may  also  produce  cystitis.  To  these 
various  causes  may  be  added  stricture  of  the  urethra  or  the  prolonged 
retention  of  urine. 

Sym]}toms  and  Diagnosis. — Pain,  and  a  desire  to  urinate  frequent- 
ly, are  the  earliest  signs  of  acute  cystitis.  The  character  of  the  pain  is 
burning  as  felt  in  the  bladder  and  deep  urethra,  and  lancinating  as  re- 


GENITO-URINARY   ORGANS. 


633 


ferred  to  the  meatus.  It  often  increases  with  the  close  of  the  effort  at 
urination,  developing  into  marked  tenesmus  as  the  last  few  drops  are 
forced  out.  It  is  exaggerated  by  direct  pressure  upon  the  abdomen,  in 
the  perinseum,  rectum,  or  vagina. 

The  febrile  movement  varies  with  the  severity  of  the  disease.  A  well- 
marked  chill  or  a  succession  of  rigors  may  occur  with  the  rise  in  tem- 
perature and  be  present  at  various  times  in  the  progress  of  the  disease. 
Microscopical  examination  of  the  urine  will  reveal  the  presence  of  epi- 
thelia  and  pus-corpuscles  in  varying  quantity.  The  urine  is  usually 
alkaline,  and,  aside  from  all  diseases  of  the  kidneys,  will  contain  a  cer- 
tain proportion  of  albumen,  which  is  always  found  when  this  fluid  is 
mixed  with  pus.  In  severe  and  unusual  cases,  shreds  of  bladder-tissue 
may  be  voided  with  the  urine. 

Treatment. — Rest  in  bed,  and  in  that  position  which  gives  the  fullest 
sense  of  comfort  to  the  patient,  is  essential.  When  the  inflammation  is 
confined  to  the  neck  and  anterior  portion  of  the  floor  of  the  bladder,  it 
is  advisable  to  elevate  the  foot  of  the  bed  from  four  to  six  inches,  and 
to  place  a  pillow  under  the  patient's  hips.  By  these  means  the  intes- 
tines and  other  organs  are  carried  by  gravity  away  from  the  diseased 
viscus,  and  at  the  same  time  the  urine  is  to  some  extent  distributed  over 
a  wider  and  less  inflamed  surface. 

Morphine  is  invaluable  in  the  alleviation  of  pain  and  the  enforcement 
of  quiet.  Hot  or  cold  applications — as  found  most  agreeable  to  the  pa- 
tient— are  useful.  The  free  administration  of  Vichy  water,  or  citrate  of 
potash  (grs.  x-xx)  at  frequent  intervals,  is  advisable.  The  rectum 
should  be  thoroughly  emptied  every  day  by  a  cold  Avater  enema. 


Fio.  566. — Nelaton's  catheter. 


In  chronic  cystitis  the  treatment  must  be  directed  to  the  cause  of  the 
disease.  Unfortunately,  it  is  too  often  incurable,  and  then  only  pallia- 
tive measures  may  be  adopted.  In  paralysis  or  atony  of  the  muscular 
walls,  or  in  the  enlarged  prostate  of  old  men,  retention  may  be  relieved 


Fig.  567. — Velvet-eyed  gum  catheters,  curved  and  straight. 


by  the  employment  of  the  soft  catheter,  and  the  condition  of  the  organ 
improved  by  irrigation.     When  it  is  desired  simply  to  emj)ty  the  blad- 


634  A  TEXT-BOOK   ON   SURGERY. 

der  without  wasMng  it  out  afterward,  the  soft-rubber  catheter  of  Nela- 
ton  (Fig.  566)  should  be  introduced.  An  instrument  of  good  size— Nos. 
12  to  14  U.  S.  scale — -with  a  perfectly  smooth  point,  should  be  selected. 
It  should  be  thoroughly  warmed  and  oiled,  and  introduced  with  the  pa- 
tient resting  on  the  back.  It  should  not  pass  beyond  the  neck  of  the 
bladder.  When  it  is  desired  to  irrigate  the  bladder,  the  double- cur- 
rent soft  catheter  (Fig*.  568)  should  be  used.     A  warm  solution  of  boracic 


Fio.  568.— Double-current  soft  catheter,  tor  irrigating  the  bladder. 


acid  (grs.  x-§  j  of  water)  is  an  excellent  remedy.  From  one  to  two  pints 
are  poured  into  a  fountain-syringe,  and  a  small  quantity  is  allowed  to 
run  out  at  the  end  of  the  tube  to  drive  out  the  air.  The  catheter  is  next 
introduced  down  to  the  constrictor  urethras  muscle,  when  the  tube  from 
the  syringe  should  be  connected  with  the  larger  end  of  the  catheter  and 
a  small  quantity  of  water  allowed  to  run  in  until  it  fills  the  instrument 
and  flows  out  at  the  smaller  tube.  By  this  manoeuvre  the  air  is  com- 
pletely expelled,  and  the  catheter  should  immediately  be  pushed  into 
the  bladder.  The  mechanism  of  this  apparatus  is  such  that  it  permits 
a  constant  and  steady  current  of  water  to  flow  in  and  out  of  the  organ 
without  over-distention.  As  soon  as  the  fluid  comes  out  perfectly  clear, 
the  operation  should  cease.  It  may  be  repeated  every  day,  and  of  tener 
when  necessary.  If  the  double  catheter  can  not  be  obtained,  an  ordi- 
nary single  instrument  will  sufBce  ;  but  the  exclusion  of  air  is  more  difii- 
cult.  Chronic  cystitis  due  to  stone  in  the  bladder,  pressure  of  other 
organs  or  a  tumor,  and  stricture  of  the  urethra,  etc.,  will,  as  a  rule,  dis- 
appear with  the  cure  of  these  various  lesions. 

In  cases  which  resist  all  conservative  measures,  incision  and  drainage 
by  the  supra-pubic  method  or  through  the  perinseum,  as  in  the  median 
or  lateral  operations  for  stone,  will  be  justifiable.  These  operations  wOl 
be  given  with  affections  of  the  prostate. 

Paralysis  of  the  bladder  may  be  partial  or  complete.  It  may  be 
caused  by  violence  inflicted  directly  to  the  organ  or  in  its  immediate 
neighborhood,  by  pathological  changes  in  its  muscular  tissue,  or  by 
traumatic  or  idiopathic  lesions  of  the  cerebrospinal  axis;  or  it  may 
occur  under  the  influence  of  certain  emotions  in  which  no  lesion  is 
recognizable. 

A  blow  upon  the  hypogastric  region  has  been  known  to  cause  tem- 
porary paralysis  of  the  bladder.  The  unskillful  introduction  of  an 
instrument,  and  the  prolonged  over-distention  of  the  organ  which  is 
common  in  prostatic  hypertrophy,  will  induce  the  same  condition.  An 
operation  xipon  the  genito-urinary  apparatus  is  almost  always  followed 
by  temporary  paresis  of  this  organ.  Operations  upon  other  portions  of 
the  economy  under  prolonged  ether  or  chloroform  narcosis  are  also  fre- 
quently followed  by  loss  of  function  in  the  bladder.     The  pressure  of 


GENITO-URINARY   ORGANS. 


635 


parturition  may  produce  a  like  result.  Severe  concussion  of  the  brain 
or  cord,  compression  of  one  or  both  of  these  ganglia  from  fracture 
or  displacement  of  their  bony  envelopes,  hsemorrhage,  aneurism  or  the 
presence  of  neoplasms  and  various  pathological  changes  in  the  me- 
ninges and  in  the  gray  and  white  matter  of  the  coi'd  and  brain,  will 
lead  to  paralysis  of  the  bladder,  varying  in  duration  with  the  severity 
of  the  lesion. 

In  the  treatment  of  this  affection  the  first  indication  is  to  prevent 
prolonged  distention  of  the  organ  by  catheterization,  which  should  be 
repeated  at  least  twice  in  twenty-four  hours.  If  a  catheter  can  not 
be  introduced,  supra-pubic  asj)iration  should  be  practiced.  Cystitis 
may  be  avoided  if  the  urine  is  carefully  and  regularly  drawn  off.  At- 
tention should  next  be  directed  to  the  removal  of  the  cause  of  the 
paralysis. 

Retention. — As  just  stated,  paralysis  of  the  muscular  walls  of  the 
bladder  is  a  cause  of  retention  of  urine.  Lesions  of  the  sensory  nerves 
of  this  organ  also  induce  retention,  which  is  proportionate  to  the  loss 
of  sensibility.  The  chief  cause  of  this  condition,  however,  is  some  form 
of  obstruction  at  the  neck  of  the  bladder  or  in  the  urethra.  As  will  be 
seen  in  treating  of  hypertrophy  of  the  prostate,  this  is  a  frequent  cause 
of  retention.  Organic  stricture,  spasm  of  the  constrictor  urethrse  (or 
"  cut-off  ")  muscle,  and  mechanical  occlusion  of  the  urethra,  are  also  com- 
mon causes  of  this  affection. 

Diagnosis. — Distention  of  the  bladder  may  be  determined  by  palpa- 
tion, percussion,  and  exploration.  In  this  condition  it  rises  well  above 
the  level  of  the  symphysis  pubis,  at  times  as  high  as  the  umbilicus,  and 
causes  tension  of  the  recti  muscles  or  protrusion  of  the  abdomen.  By 
direct  pressure,  the  desire  on  the  part  of  the  patient  to  urinate  may 
usually  be  increased,  and,  if  the  abdominal  walls  are  thin,  the  spherical 
chai'acter  of  the  organ  may  be  recognized.  Upon  percussion,  dullness 
is  present  and  fluctuation  may  be  appreciable. 

In  siqjpression  of  urine  aU  of  these  symptoms  are  absent,  the  skin  is 
usually  hot  and  dry,  the  pulse  rapid  and  full,  and  the  temperature  is 


Filiiorm  catheter. 


several  degrees  above  the  normal.  The  introduction  of  a  catheter  or 
puncture  of  the  bladder  with  a  small-sized  aspirator-needle,  just  at  the 
upper  level  of  the  symphysis,  wiU  determine  the  diagnosis. 

In  treatment,  the  evacuation  of  the  contents  of  the  organ  is  the  im- 
mediate indication.     The  patient  should  be  put  to  bed  and  given  the 


636 


A   TEXT-BOOK   ON   SURGERY. 


benefit  of  a  full  dose  of  opium.  This  agent  is  useful  in  alleviating  pain, 
in  securing  relaxation  of  the  muscular  elements  of  the  urethra  and  pros- 
tate, and — by  producing 
diaphoresis — in  diverting 
fluids  from  the  kidneys 
to  the  excretory  appara- 
tus of  the  skin.  A  soft- 
rubber  (Nelaton)  cathe- 
ter should  be  preferred ; 
but,  if  this  can  not  be 
introduced,  a  firmer, 
olive-pointed  instrument 
(Fig.  571)  should  be  em- 
ployed. The  silk-woven 
and  gummed  catheter 
(Figs.  572  and  573)  is  also 
a  useful  instrument,  and 
if,  on  account  of  its  elas- 
ticity, it  can  not  be  introduced,  the  stylet  of  Prof.  Keyes  (Fig.  574) 
should  be  inserted  into  the  catheter  to  give  it  the  required  stiffness.    The 

_^ „- — ■,„..„- — ^        ir\ 

(^.TIEMANN  &.  CO.  ^*  \^ 

Fig.  574. — Dr.  Keyes's  wire  stylet. 

metal  catheter  (Fig.  575),  if  properly  constructed  and  carefully  intro- 
duced, can  be  made  to  safely  overcome  any  ordinary  resistance.  It 
should  be  of  heavy  silver,  strong,  perfectly  smooth,  and  should  have  a 
ciirve  corresponding  to  that  of  the  normal  urethra.  In  size  it  should  cor- 
respond to  No.  10, 12,  or  14,  U.  S.,  and  the  larger  sizes  should  be  preferred. 
The  introduction  of  a  metal  catheter  or  sound  through  the  normal 
urethra  into  the  bladder  is  accomplished  as  follows  :  The  jjatient  is 
placed  upon  the  back  with  the  lower  extremities  parallel  with  the  body. 
If  TT],  XX  of  a  4-i3er-cent  solution  of  cocaine  hydrochlorate  are  introduced, 


Tig.  570.- — Black  French  catheter,  blunt-pointed. 


Fig    571  — Black  Fiench  catheter    olne  pointed 


Fig.  572. — Gummed  silk-woven  catheter. 


Fig.  573. — Gummed  silk-woven  bougie. 


Fig.  575. — Strong  silver  catheter. 


the  normal  sensibility  will  be  lost  as  far  back  as  the  compressor  mus- 
cle. The  catheter  is  placed  in  Avater  at  a  temperature  of  about  105°  to 
110°  F.,  and,  when  warmed  through,  is  lubricated  with  sweet-oU  or 
vaseline.  If  the  operator  is  right-handed,  it  is  best  to  stand  on  the 
left  side  of  and  facing  the  patient.  The  penis  is  seized  Avith  the  left 
hand  and  held  steady  while  the  end  of  the  catheter  is  carried  into  the 
meatus.  At  this  stage  of  the  procedure  the  shaft  of  the  sound  is  par- 
allel with  Poupart's  ligament,  and,  as  soon  as  the  first  four  inches  have 


GENITO-URINARY  ORGANS. 


637 


passed  into  the  urethra,  while  it  still  descends,  the  handle  is  gradually 
brought  toward  the  median  line.  The  point  is  now  engaged  in  the  bulb, 
or  at  the  anterior  layer  of  the  triangular  ligament,  and  the  shaft  is  about 
perjDendicular  to  the  plane  of  the  abdomen.  Without  exercising  any 
force  to  push  the  instrument  in  the  direction  of  the  bladder,  the  handle 
is  slowly  and  steadily  carried  downward  until  the  shaft  is  parallel  with 
the  anterior  surface  of  the  thighs.  While  this  manoeuvre  is  being  effect- 
ed, the  point  is  tilted  from  the  floor  of  the  bulb  into  the  membranous 
portion  which  offers  the  greatest  resistance,  not  only  because  it  is  the 
narrowest  part  of  the  canal,  but  because  the  compressor-urethrse  muscle 
must  be  overcome.  All  the  time  that  the  instrument  is  being  pushed 
toward  the  bladder  the  penis  should  be  pulled  over  the  catheter,  for  in 
this  way  the  lining  membrane  is  put  upon  the  stretch  and  the  introduc- 
tion greatly  facilitated.  When  the  neck  of  the  bladder  is  reached,  the 
instrument  will  usually  have  penetrated  a  distance  of  eight  or  nine  inch- 
es. It  should  be  borne  in  mind  that  even  a  silver  catheter  is  capable  of 
doing  great  damage  to  the  urethra  if  improper  force  is  employed  in  its 
introduction.  There  is  usually  no  resistance  except  by  the  comjaressor 
muscle,  and  this  is  only  spasmodic.  If  the  point  of  the  instrument  is 
kept  well  against  the  obstruction  by  depressing  the  handle  between  the 

thighs,  it  will  slip  by  with  the  first 
relaxation  of  this  muscle.  The 
methods  of  introducing  an  instru- 
ment into  the  bladder  in  abnor- 
mal conditions  of  the  urethra  and 
prostate  will  be  given  later. 

If  it  is  found  impossible  to 
reach  the  bladder  by  the  urethra, 
the  urine  should  be  evacuated  by 
the  aspirator.  The  apparatus 
shown  in  Fig.  576  will  give  gen- 
eral satisfaction.  The  needle  and 
entire  instrument  should  be  care- 
fully cleansed  and  disinfected  in 
l-to-20  carbolic-acid  solution,  both 
before  and  after  it  is  used.  The 
smallest  needle  will  suffice.  If 
its  introduction  is  preceded  by  a 
small  hypodermic  syringe-needle, 
and  TTi  x-xx  of  4-per-cent  cocaine 
are  injected,  the  operation  will  be 
painless.  The  piibes  being  shaved 
and  disinfected,  and  everything 
in  readiness,  the  needle  is  filled 
with  the  carbolic-acid  solution 
and  closed  by  turning  the  cock 
((?,  Fig.  576) ;  the  air  is  exhausted  from  the  receiver  (3)  by  working 
the  pump  {4-).     The  patient  should  be  placed  in  the  sitting  jjosture, 


Fig.  5T6. — Tiemann  &  Co.'s  aspirator. 


638 


A  TEXT-BOOK   ON   SURGERY. 


and  tlie  needle  introdn.ced  a  half-inch  above  the  symphysis  and  pushed 
directly  backward  a  distance  of  two  inches.     The  cock  is  now  opened, 
and  the  urine  flows  into  the  bottle.     If  it  becomes  necessary  to  empty 
the  receiver,  the  stop-cock  should  be  turned,  to  prevent  the  entrance  of 
air  into  the  bladder. 

When  the  character  of  the  obstruction  or  disease  is  such  that  a  per- 
manent urinary  fistula  is  necessary,  this  may  be  made  through  the  peri- 
naeum  or  directly  from  the  anterior  wall  of  the  rectum  into  the  base  of 
the  bladder.     Of  the  two  procedures,  the  former  is  preferable. 

The  incision  is  the  same  as  for  lateral  lithotomy.  To  prevent  the 
wound  from  closing,  a  soft  catheter  should  be  carried  through  the  incis- 
ion into  the  bladder  and  allowed  to  remain  for  several  weeks.  The  self- 
retainina;  instrument  shown  in  Fig.  577  will  give  the  best  satisfaction. 


e.TIEMANN  &.C0. 
Fig.  577. — Holt's  self-retaining  catheter. 


The  fistula  will  become  permanent  as  soon  as  its  walls  are  covered  with 
epithelia.  Although  the  annoyance  from  this  condition  of  incontinence 
is  great,  it  is  preferable  to  a  vesico-rectal  fistula,  where  the  irritation  of 
the  bowel  is  the  cause  of  much  discomfort  and  prostration. 

The  recto-vesical  operation  is  performed  in  this  way  :  While  the 
bladder  is  distended,  the  finger  of  the  left  hand  is  oiled  and  introduced 
into  the  rectum  until  the  tip  passes  above  the  prostate.  A  trocar  and 
canula  (Fig.  678)  is  guided  along  the  finger  to  a  point  just  beyond  the 


Fig.  578. — Buck's  rectum  trocar. 


prostate,  where  it  is  turned  directly  upward  and  forced  through  the 
floor  of  the  bladder.  The  trocar  is  withdrawn  and  the  urine  allowed  to 
escape.  If  this  opening  is  not  sufiicient  to  allow  of  the  satisfactory 
drainage  of  the  bladder,  it  may  be  enlarged. 

Incontinence  of  Urine. — Incontinence  of  urine  occurs  when  the  com- 
pressor urethrge  and  the  muscular  elements  of  the  prostate  are  para- 
lyzed. It  is  present  in  a  proportion  of  cases  of  prolonged  over-distention 
of  the  bladder,  the  pressure  from  behind  overcoming  the  normal  resist- 
ance of  these  muscles.  Irritation  of  the  bladder  from  any  cause  may 
produce  tenesmus  of  this  organ,  and  consequent  inability  to  retain  the 
urine.  This  is  especially  apt  to  occur  in  children  during  sleep,  in  the 
earlier  hours  of  morning,  when  the  bladder  is  full. 


NEW  FORMATIONS  AND  TUMORS   OF  THE  BLADDER.      639 


Women  are  more  frequently  affected  with,  incontinence  than  men, 
which  fact  is  explained  not  only  in  the  better  tone  of  the  muscular 
system  in  males,  but  in  the  absence  of  the 
prostatic  muscle  in  females,  which,  according 
to  Henle,  is  of  great  aid  in  holding  the  ure- 
thra closed.  The  general  relaxation  of  the 
pelvic  muscles  as  a  result  of  parturition  may 
also  account  for  the  more  frequent  occurrence 
of  incontinence  of  urine  in  women. 

The  palliative  treatment  consists  in  apply- 
ing a  urinal  for  the  reception  of  the  water  as 
it  dribbles  away  (Fig.  579). 

Curative  measures  should  be  directed  to  a 
removal  of  the  cause  of  incontinence.  These 
will  be  given  with  the  various  lesions  of 
which  it  is  a  symptom.  In  the  nocturnal 
incontinence  of  children  the  habit  may  be 
corrected  by  causing  the  patient  to  be  awakened  and  the  bladder  emp- 
tied once  or  twice  during  the  night. 

Dr.  H.  Marion-Sims  reported  to  the  New  York  Obstetrical  Society  a 
number  of  distressing  cases  of  incontinence  of  urine  in  adult  females. 
These  cases  were  cured  by  gradual  and  frequently  repeated  distention  of 
the  bladder.  His  method  was  to  introduce,  by  means  of  a  Davidson 
syringe  through  a  catheter,  cold  or  tepid  water  beginning  with  3  j,  hold- 
ing this  in  for  some  minutes  and  then  allowing  it  to  be  evacuated.  The 
next  day  an  ounce  and  a  half  was  employed,  and  this  was  continued 
untU  one  pint  or  more  was  easily  contained.  In  this  manner  tolerance 
was  established  and  a  cure  effected. 


Fig.  579. — Female  and  male  urinala, 
for  iucontineace. 


Neav  Formations  and  Tumors  of  the  Bladder. 

PapiUomata,  or  "  villous  growths,"  are  among  the  more  frequent 
neoplasms  of  this  organ.  They  are  located  usually  upon  the  floor  and 
lower  portions  of  the  lining  membrane.  There  may  be  one  or  more. 
As  many  as  forty  of  these  neoplasms  have  been  removed  from  a  single 
bladder.  Microscopically,  they  are  composed  of  a  series  of  vascular 
loops  or  network,  covered  with  epithelia  of  the  same  type  as  the  normal 
cells  of  the  mucous  membrane,  only  of  more  luxuriant  growth. 

The  symptoms  which  present  themselves  in  the  earlier  stages  of  the 
development  of  vesical  papilloma  are  obscure.  When  a  single  tumor 
exists,  and  is  not  of  rapid  growth,  the  bladder  may  become  tolerant  of 
its  presence.  Under  other  conditions,  symptoms  of  irritation,  frequent 
micturition,  and  tenesmus  may  be  present.  If  the  growth  be  situated 
near  the  outlet  of  the  bladder,  it  may  interfere  with  the  escape  of  urine. 
Hsematiiria  is  of  frequent  occurrence  in  coanection  with  this  variety  of 
tumor,  and  is  due  to  rupture  of  the  capillaries  from  ulceration  caused  by 
the  action  of  the  urine  upon  the  tufts.  An  exacerbation  of  haemorrhage 
is  apt  to  follow  the  introduction  of  the  sound.     An  examination  of  the 


640  A  TEXT-BOOK   ON   SURGERY. 

iirine  may  demonstrate  the  presence  of  particles  of  tlie  papillomatous 
tissue.  If  a  sound  be  introduced  while  the  bladder  is  fairly  distended, 
so  as  to  efface  the  folds  into  which  the  mucous  membrane  is  thrown 
when  the  organ  is  contracted,  the  presence  of  the  tumor  may  be  recog- 
nized by  the  resistance  offered  as  the  convexity  of  the  sound  is  swept 
along  the  floor  and  sides  of  the  organ. 

The  employment  of  the  cystoscope  will  be  of  value  in  determin- 
ing the  presence  and  location  of  a  neoplasm  or  foreign  body.  In 
using  this  instrument,  the  bladder  should  be  washed  out  thorough- 
ly and  then  injected  with  a  warm  clear  saline  solution  (about  eight 
ounces). 

The  treatment  is  to  open  into  the  bladder,  by  the  supra-pubic  meth- 
od, and  remove  the  growths  with  the  forceps,  or  scrape  them  off  with 
Volkmann's  spoon,  guided  by  the  finger.  A  medium-size  Spencer 
Wells  fenestrated  ovarian  sac  forceps  I  have  found  very  useful  in 
twisting  off  tumors  of  the  bladder.  The  details  of  the  operation  are 
given  with  supra-pubic  cystotomy  for  stone. 

Fibroma  and  myxoma  of  the  bladder  may  be  considered  as  next  in 
order  of  frequency.  They  belong  to  the  connective-tissue  ty^De  of  new 
formations,  are  less  vascular,  and  of  slower  development,  although  at 
times  they  attain  considerable  size.  The  base  of  the  organ  is  the  usual 
location  of  the  tumor.  The  symptoms  are  about  the  same  as  those  in 
papilloma,  excepting  hsemorrhage.  The  diagnosis  will  depend  upon  the 
appreciation  of  the  growth  by  the  sound,  or  by  rectal  palpation  with 
the  sound  in  the  bladder.  If  the  character  of  the  lesion  can  not  be  ac- 
curately determined,  and  the  symptoms  of  irritation  are  present,  a  peri- 
neal exploratory  incision  may  be  made.  The  treatment  consists  in  the 
removal  of  the  mass  by  the  operation  Just  given. 

Other  forms  of  benign  tumors  of  the  bladder  are  so  rare  as  scarcely 
to  deserve  mention.  Among  the  new  formations  myoma  is  occasionally 
found,  while  of  the  tumors  hydatid  cysts  are  sometimes  met  with.  These 
formations  are  amenable  to  the  same  rules  of  treatment  as  above  laid 
down. 

Of  the  malignant  diseases  of  this  organ,  sarcoma  is  extremely  rare  ; 
while  of  the  carcinomata,  the  epithelial  variety  is  by  far  the  most  fre- 
quent. Scirrhus  may,  however,  originate  here.  The  symptoms  differ 
only  in  degree  in  the  malignant  as  compared  with  the  benign  tumors  Just 
described.  The  gradual  development  of  the  cachexia,  which  is  a  part  of 
cancer,  may  alone  lead  to  a  positive  diagnosis.  Exploration  with  the 
sound  and  rectal  examination  may  determine  the  suspicious  character  of 
the  disease  by  the  extent  of  the  infiltration  in  the  tissues  around  the 
bladder. 

Operative  interference  is  rarely  Justifiable,  for  the  reason  that  the 
disease  is  almost  of  necessity  so  far  advanced  before  it  is  recognized 
that  a  thorough  removal  is  impossible. 

The  Urine — Quantity. — The  average  quantity  of  urine  excreted  by 
the  kidneys  of  the  normal  adult  is  about  fifty-six  ounces  in  twenty-four 
hours.     This  quantity  varies  with  the  amount  of  fluids  ingested,  the  ac- 


THE   URINE— UREA.  641 

tivity  of  the  sweat-glands,  and  the  elimination  of  liquids  by  the  aliment- 
ary canal. 

It  is  of  an  amber-  or  straw-color,  which  is  due  to  the  presence  of 
indican  and  urobUine.  The  greater  the  quantity,  as  a  rule,  the  lighter 
the  color.  It  is  dark  in  proportion  to  the  intensity  of  the  destructive 
changes  in  tissue,  as  in  prolonged  exertion,  or  during  the  progress  of 
fevers.  Carbolic  acid  and  bUe  turn  the  urine  brown  or  greenish-black, 
and  blood  (hsematuria)  gives  it  its  characteristic  tinge.  The  normal  odor 
of  urine  is  peculiar  to  itself.  An  artificial  aroma  is  easily  substituted  by 
the  ingestion  of  certain  foods  and  drinks,  as  gaultheria,  turpentine,  as- 
paragus, etc. 

Reaction. — Healthy  fresh  urine  is  acid  in  reaction,  changing  litmus 
from  blue  to  the  faintest  red  or  rose  color.  Acid  urine  will  at  times  be- 
come alkaline  within  a  few  minutes  after  its  discharge.  The  ingestion 
of  alkaline  substances  in  vegetable  foods  gives  a  neutral  or  alkaline 
character  to  the  urine  passed  within  a  short  time  after  eating.  The  same 
is  true  of  the  alkaline  salts,  potash,  soda,  etc.  Uiine,  alkaline  in  reac- 
tion as  it  leaves  the  urethra — the  alkalinity  not  due  to  food  or  medica- 
tion— is  an  indication  of  disease  of  the  bladder  or  pelvis  of  the  kidney. 

Specific  Q-ramty.  — The  specific  gravity  varies  in  the  normal  condition 
from  1-005  to  I'OSO.  Usually  the  increase  in  quantity  is  accompanied  by 
a  smaller  proportion  of  solids  and  a  consequent  lower  specific  gravity. 
This  is  not  the  case  in  diabetes,  where  the  quantity  is  abnormally  large, 
while  the  urinometer  may  register  as  high  as  1030-1040. 

It  becomes  a  matter  of  great  importance  to  determine  through  the 
chemical  and  microscopical  analysis  of  the  urine  the  condition  of  the 
organs  which  excrete  this  fluid  and  those  through  which  it  passes  in  its 
way  to  the  exterior.  Certain  conditions  of  the  kidneys,  as  in  Bright's 
disease,  render  the  prognosis  of  a  surgical  procedui'e  more  grave,  and 
may  justify  a  modification  of  the  treatment. 

Urea. — Urea  is  the  result  of  destructive  tissue  metamorphosis.  It  is 
increased  by  the  ingestion  of  nitrogenized  food  and  by  excessive  muscu- 
lar exercise.  The  average  daily  quantity  excreted  by  the  urine  is  about 
four  hundred  and  fifty  grains,  which,  with  the  estimate  of  the  daily  urine 
at  fifty-six  ounces,  is  about  gr.  J  of  urea  to  3  j  of  the  urine. 

Any  marked  diminution  of  this  proportion  indicates  failure  in  the 
elimination  of  the  products  of  waste  in  the  tissues  and  the  danger  of 
urcRmia.  The  simplest  quantitative  test,  and  one  suflaciently  exact  for 
practical  purposes,  is  the  following :  To  make  it,  it  is  required  to  have 
Labarraque's  solution,  metallic  mercury,  a  saturated  solution  of  common 
salt,  and  a  graduated  glass  tube,  with  a  capacity  of  several  cubic  inches, 
and  of  a  caliber  not  so  large  but  that  the  open  end  can  be  readily  closed 
by  the  thumb. 

Fill  the  tube  one  third  full  of  mercury ;  on  top  of  this  pour  3  ss.  of 
urine,  fill  the  balance  of  the  tube  with  Labarraque's  solution  poured  in 
quickly,  and  as  quickly  close  the  end  of  the  tube  with  the  thumb.  In- 
vert the  tube,  carry  the  end  well  below  the  surface  of  the  saturated  solu- 
tion of  salt,  and  then  remove  the  thumb,  allovdng  the  mercury  to  escape, 

41 


642  A  TEXT-BOOK   ON   SURGERY. 

while  the  salt  water  rushes  in  to  take  its  place.  Allow  the  tube  to  re- 
main in  this  position  about  six  hours,  or  until  the  bubbling  entirely 
fceases.  The  volume  of  gas  which  rises  to  the  top  of  the  tube  represents 
the  proportion  of  urea  in  the  specimen  examined.  If  a  half- drachm  is 
used,  every  cubic  inch  of  displacement  of  the  liquid  within  the  tube  is 
equal  to  0-645  of  a  grain  of  urea.  Multiplying  this  by  the  inches  or 
fractions  of  an  inch  of  gas  will  give  the  quantity  of  urea  in  3  ss.  of 
urine. 

Albumen. — Albumen  in  the  urine  of  one  in  health  is  exceedingly 
rare.  It  is  said  not  to  indicate  disease  if  present  in  small  quantity  soon 
after  the  excessive  ingestion  of  albuminous  foods. 

In  isolated  cases  its  presence  is  ephemeral.  In  a  case  presented  be- 
fore the  New  York  Pathological  Society,  by  Prof.  Janeway,  albuminuria 
could  be  produced  at  will  by  increased  mental  activity.  In  a  condition 
of  repose  no  trace  was  discoverable. 

Albumen  is  always  present  in  urine  which  contains  pus,  independent 
of  any  affection  of  the  kidneys. 

It  may  be  recognized  by  the  tests  with  heat  and  nitric  acid.  To  em- 
ploy the  heat-test,  iill  a  ttibe  half  full  of  urine,  to  which,  if  alkaline  or 
faintly  acid  in  reaction,  one  or  two  drops  of  acetic  acid  should  be  added. 
Hold  the  tube  so  that  the  flame  of  the  ^irit-lamp  will  heat  the  upper 
inch  of  urine.  If,  just  before  the  boiling-point  is  reached,  a  cloudy 
white  film  pervades  the  heated  mass,  the  presence  of  albumen  is  demon- 
strated. 

The  nitric-acid  test  is  not  so  reliable  as  the  preceding.  When  albu- 
men is  thought  to  be  demonstrated  by  its  iise,  the  heat- test  should  be 
applied  to  confirm  it.  Into  a  small  test-tube  drop  from  lU  x-xx  of  pure 
nitric  acid.  Hold  the  tube  slanting  and  allow  the  urine  from  a  glass 
pipette  to  run  gently  down  the  side  until  it  floats  upon  the  acid.  Albu- 
men is  indicated  by  a  white  or  cloudy  ring  formed  in  the  layer  of  urine 
immediately  in  contact  with  the  acid. 

Sugar. — The  urine  of  diabetes  melUtus  has  a  high  specific  gravity,  is 
passed  in  great  quantity,  and  has  a  characteristic  sweet  odor.  This  form 
of  sugar  may  be  recognized  by  Trommefs  test,  in  which  an  oxide  of  cop- 
per is  produced  by  boiling  diabetic  urine  (grape-sugar)  with  a  solution 
of  potash  and  copper.  Fill  a  test-tube  for  one  inch  with  the  suspected 
urine,  and  add  one  or  two  drops  of  a  solution  of  sulphate  of  copper — 
just  enough  to  give  the  whole  a  pale-blue  tint.  Add  the  potash  solution 
in  quantity  equal  to  one  half  the  urine.  When  sugar  is  present,  a  pale- 
blue  hydrated  oxide  of  copper  will  be  thrown  down  and  immediately  re- 
dissolved.  If  the  mixture  is  now  slowly  heated  to  near  the  boiling- 
point,  a  reddish-brown  suboxide  of  copper  will  be  precipitated. 

When  a  quantitative  analysis  is  desired,  the  fermentation-test  will  be 
found  simple  and  sufiiciently  accurate  for  practical  use.  Fill  a  wide- 
mouthed  bottle  with  the  urine,  and  register  the  specific  gravity  at  the 
time.  Place  a  small  piece  of  yeast  in  the  urine,  and  set  it  aside  in  a  warm 
place  for  from  twelve  to  eighteen  hours  until  fermentation  has  occurred, 
and  again  take  the  specific  gravity.     The  difference  in  degrees  of  the  uri- 


PUS-  AND   BLOOD-CORPUSCLES.  643 

nometer,  as  registered  before  and  a,f ter  fermentation,  will  represent  the 
nnmber  of  grains  of  sugar  in  tlie  ounce  of  urine. 

Pus-  and  Blood-Corpuscles — Epithelia. — Pus-cells  in  the  urine  may 
come  from  an  intiammation  in  any  portion  of  the  niinary  tract,  from  the 
kidney  to  the  meatus,  or  from  the  communication  of  a  sinus  or  abscess 
with  the  iirinary  apparatus.  Urine  containing  pus  may  be  acid,  alka- 
line, or  neutral  in  reaction.  In  acid  urine  the  corpuscles  are  prominent 
and  easily  recognized ;  when  the  reaction  is  alkaline,  they  are  usually 
destroyed,  and  appear  as  ropy  or  gelatinous  strings,  more  resembling 
mucus  than  pus.  If  the  urine  is  examined  immediately  after  being 
passed,  a  few  corpuscles  may  be  recognized.  When  allowed  to  stand  for 
some  minutes,  the  pus-cells  collect  in  the  bottom  of  the  vessel.  Ex- 
amined with  the  microscope,  they  are  seen  to  be  spherical  and  faintly 
grantilar.  On  account  of  the  absorption  of  water,  they  are  swollen  and 
less  distinct  than  pus-cells  from  a  I'ecent  abscess.  The  addition  of  acetic 
acid  renders  the  nuclei  more  distinct.  The  source  of  pus  found  in  the 
urine  may  frequently  be  determined  from  the  symptoms  present,  to- 
gether with  the  microscopical  appearances  of  the  urine.  If  with  the 
pus-corpuscles  flat,  large  epithelia  are  abundant,  the  inflammatory  pro- 
cess is  in  all  probability  situated  in  the  bladder  where  these  epithelia 
belong.  In  females  a  larger,  flat  epithelium  from  the  vagina  often  finds 
its  way  into  the  urine.  The  cells  from  the  vagina  are  more  often  disposed 
in  drifts  or  groups  than  the  bladder  epithelia.  Large  spherical  or  po- 
lygonal cells  may  come  from  the  kidney-tubules  or  the  male  urethra. 
They  are  about  twice  the  size  of  a  pus-corpuscle.  AVhether  they  are 
derived  from  the  kidney  or  the  urethra  may  in  great  part  be  determined 
by  the  presence  or  absence  of  urethritis.  Conical  or  ham-shaped  cells 
may  come  from  the  pelvis  of  the  kidney,  prostate,  and  glandular  appa- 
ratus of  the  urethra.  They  are  usually  not  so  abundant  as  the  other 
varieties. 

Hematuria. — Blood  in  the  urine  may  come  from  traumatic  or  idio- 
pathic hsemoiThage  into  the  Malpighian  tufts  or  kidney-tubules ;  from 
the  pelvis  or  ureters  as  a  result  of  calculi  or  ulceration  ;  from  the  bladder 
as  a  result  of  instrumentation,  calculus,  wounds,  foreign  body,  neo- 
plasms, ulceration,  parasites,  or  the  hsemorrhagic  diathesis ;  from  the 
prostate  or  accessory  organs  and  the  urethra. 

The  administration  of  certain  remedies  may  account  for  the  appear- 
ance of  blood  in  the  urine.  Hsematuria  occurs  at  times  as  a  symp- 
tom of  malarial  fever,  and,  in  women,  as  a  form  of  vicarious  men- 
struation. 

Blood  in  the  urine  may  be  recognized  by  its  characteristic  coagula,  by 
the  red  or  reddish-brown  color  it  imparts  to  this  fluid,  the  presence  of 
the  corpuscles  under  the  microscope,  or  the  fibriuous  casts  of  the  tubules 
of  the  kidney  or  ureters.  In  rare  instances  the  blood-disks  are  entirely 
destroyed,  and  the  coloring-matter  set  free.  This  condition  is  apt  to 
occur  in  ammoniacal  urine. 

When  iirine  containing  blood  is  boiled,  a  white  or  cloudy  coagulura 
is  formed,  its  density  depending  upon  the  quantity  of  blood  present. 


644  A  TEXT-BOOK  ON   SURGERY. 

If  bloody  urine  is  allowed  to  stand  without  being  agitated,  tbe  cor- 
puscles settle  to  tlie  bottom  of  the  vessel,  and  may  be  recognized  by  their 
red  or  amber  color.  Under  the  microscope  they  may  assume  different 
shapes.  In  acid  urine  the  disks  retain  their  bi-concave  conformation  for 
a  long  time.  When  the  haemorrhage  is  slight,  they  float  isolated  ;  if  pro- 
fuse, they  may  be  caught  in  coagula  or  collect  in  rouleaux.  If  the  re- 
action is  feebly  acid,  or  where  the  corpuscles  are  submitted  for  a  consid- 
erable time  fco  the  action  of  the  urine,  they  lose  their  bi-concave  shape, 
and  become  distended,  swollen,  and  spherical.  They  may  be  recognized 
from  pus-corpuscles  by  their  smaller  size,  transparency,  and  in  not  con- 
taining granular  bodies.  At  times  they  retain  their  flat  shape  and  appear 
with  serrated  edges. 

Blood-casts  usually  come  from  the  kidney-tubules,  and  are  composed 
of  fibrin  in  which  the  red  disks  are  entangled  in  varying  proportion. 
In  some,  large  clusters  or  groups  of  blood-corpuscles  are  seen,  with  an 
occasional  epithelial  cell  from  the  kidney  or  urinary  passages.  When 
the  disks  have  been  completely  destroyed,  as  in  the  decomposition  of 
the  coloring-matter  in  amraoniacal  urine,  and  the  organic  elements  of  the 
blood  are  not  recognizable  with  the  microscope,  the  spectroscope  may 
be  relied  upon  to  demonstrate  the  presence  of  the  coloring-matter. 

In  determining  the  source  of  blood  in  hgematuria  the  following  points 
should  be  considered  :  When  the  bleeding  is  urethral,  the  first  discharge 
of  urine  is  most  deeply  colored.  A  clot  of  blood  preceding  or  accom- 
panying the  discharge  of  urine  indicates  urethral  haemorrhage.  In  males, 
if  spermatozoa  are  entangled  in  the  coagula,  the  suspicion  of  hgemor- 
rhage  from  the  vasa  de/erentia  or  prostatic  apparatus  is  entitled  to  con- 
sideration, although  the  fact  must  not  be  overlooked  that  these  elements 
may  mingle  in  the  urethra  with  blood  from  any  part  of  the  urinary 
passages. 

When  the  bleeding  is  from  the  pelvis  of  the  kidney,  pain  and  other 
symptoms  of  stone  or  pyelitis  will  often  precede  the  haematuria.  Not 
infrequently,  however,  the  haemorrhage  is,  next  to  the  presence  of  pus 
in  the  urine,  the  first  indication  of  pyelitis. 

In  haemorrhage  from  the  bladder  there  are  often  symptoms  of  cystitis 
which  will  point  directly  to  this  organ  as  the  source  of  the  bleeding. 
In  differentiating  the  origin  of  blood  from  the  kidneys,  ureters,  and  the 
bladder,  the  method  of  Thompson  and  Van  Buren  may  be  resorted 
to  with  success.  Introduce  a  soft  catheter  just  within  the  neck  of  the 
bladder,  draw  off  the  contained  urine,  and  wash  out  the  organ  with 
clean  water.  If,  during  the  irrigation,  the  water  which  flows  away 
contains  blood,  the  haemorrhage  is  from  the  bladder- walls.  If  it  flows 
away  clear,  then  empty  the  bladder,  place  the  finger  over  the  end  of  the 
catheter,  allow  it  to  remain  introduced,  and  wait  until  a  smaU  quantity 
of  urine  has  accumulated.  This  is  drawn  off,  and,  if  it  is  bloody,  and 
if  the  clear  water  now  thrown  in  comes  out  unstained,  the  inference  is 
fair  that  the  bleeding  is  from  the  ureters  or  beyond. 

Haemorrhage  from'the  urethra  is  rare  except  from  violence,  the  lodg- 
ment of  calculi,  or  from  ulceration. 


STONE  IN  THE   BLADDER.  645 

Hsematuria  due  to  parasitic  lodgment  in  the  walls  of  tlie  bladder  is 
exceedingly  rare  in  this  country.  In  1883  a  young  man  of  white  parents 
— a  native  of  Natal,  Africa — came  under  my  care  on  account  of  chronic 
hsematuria.  He  was  at  this  time  twenty-six  years  of  age,  and  had  had 
bloody  urine  at  intervals  for  thii'teen  years.  His  health  was  not  seriously 
impaked.  The  urine  was  faintly  acid  ;  specific  gravity  1'020,  with  only  a 
trace  of  albumen,  which  was  readily  accounted  for  by  the  slight  amount 
of  blood.  About  the  middle  and  toward  the  last  stage  of  the  act  of  mic- 
turition, a  few  strings  of  clotted  blood  were  dis- 
charged. Placing  these  under  the  microscope,  I 
discovered  a  number  of  bodies  (Fig.  580)  shaped 
much  like  a  watermelon-seed,  except  that  the  small 
end  was  more  pointed.  These  were  evidently  the 
eggs  of  the  parasite  known  as  Bilharzia  JKEmato- 
hia,  the  hsematuria  resulting  from  the  rupture  of 
^'"zif  hffi^atobfa.*''^f,'cre-  Capillaries  caused  by  the  presence  of  nests  of  these 
nated  blood -disks.    3,     q^^  in  the  mucous  membrane  of  the  bladder.     This 

Epithelium.   4,  Pus-cell.  . 

(From  the  author's  case.)  disease  IS  frequent  m  Africa  and  Asia,  but  almost 
unknown  in  North  America.  The  body  of  the  male 
parasite  is  about  four  lines  in  length,  thread-like,  and  flattened  ante- 
riorly (Aitken)  ;  the  female  a  little  shorter  and  more  delicate.  They 
inhabit  by  preference  the  portal  vein  and  the  walls  of  the  bladder.  In 
treating  my  patient  I  saturated  him  with  large  doses  of  santonin  for  a 
week,  and  injected  the  bladder  daily  with  alcohol,  beginning  with  a 
l-to-20  solution,  and  increasing  it  to  the  extreme  degree  of  tolerance  by 
the  bladder.  The  patient  improved  in  every  respect,  but  the  hsematu- 
ria was  not  entirely  arrested  when  he  returned  to  Africa  in  November, 
1883,  since  which  time  I  have  not  heard  from  him. 

The  parent  distoma  is  killed  by  high  febrile  movement,  and  with  its 
death  the  hsematuria  ceases. 

The  treatment  of  hsematuria  must  be  directed  to  the  disease  of  which 
it  is  a  symptom.  The  patient  should  be  required  to  remain  in  the  re- 
cumbent j)Osture.  The  administration  of  the  fluid  extract  of  ergot,  3  j-ij, 
is  highly  recommended  without  regard  to  the  source  of  the  bleeding. 
Large  doses  of  citrate  of  potash  will  prove  beneficial  in  rendering  the 
urine  less  irritating.  Opium  is  advisable,  not  only  on  account  of  the 
relief  from  pain  it  affords,  but  because  it  secures  complete  quiet,  which 
is  essential,  and  prevents  the  too  frequent  evacuation  of  the  bladder. 

When  the  hfemorrhage  is  from  this  organ,  and  does  not  yield  to  the 
measures  above  given,  the  injection  of  cold  or  hot  water,  or  of  astringent 
solutions,  may  be  employed.  If  villous  growths  are  present,  they  should 
be  removed  by  cystotomy. 

Stone  in  the  Bladder. 

Urinary  calculi  may  form  in  any  portion  of  the  kidney,  in  the  pelvis 
or  ureters,  in  the  bladder  or  urethra.  They  are  concretions  of  the  va- 
rious inorganic  substances  which  are  common   to  the  urine.     Organic 


646  A  TEXT-BOOK   ON   SURGERY. 

particles,  such  as  epithelia,  mucus,  and  various  iniiammatory  products, 
often  enter  into  tlie  formation  of  calculi.  When  an  aggregation  of  the 
urinary  salts  occurs  within  the  kidney-tubules,  the  probabilities  are  that 
the  stone  so  formed  will  remain  imprisoned  in  this  organ  (renal  calculus) 
until  removed  by  ulceration  or  operation.  Forming  in  the  larger  straight 
tubes  of  the  pyramids,  a  urinary  concretion  may,  while  yet  minute,  es- 
cape into  the  calix  and  pelvis,  and  pass  down  the  ureter  into  the  blad- 
der, or  remain  lodged  in  the  pelvis  or  excretory  duct. 

It  is,  moreover,  probable  that  the  majority  of  calculi  found  in  the 
bladder,  or  passed  by  the  urethra,  originate  as  concretions  in  the  straight 
tubes,  calices,  or  pelves  of  the  kidneys,  whence  they  drift  outward  to 
the  bladder,  and  there  by  continued  accretion  become  large  enough  to 
attract  attention,  even  if  the  transit  along  the  ureter  was  unnoticed. 
Undoubtedly  a  fair  proportion  of  vesical  calculi  are  formed  in  this  organ 
proper,  and  the  greater  number  of  these  may  be  grouped  in  the  class  of 
calculi  which  form  around  nuclei  composed  of  foreign  substances,  or 
animal  matter,  such  as  epithelia,  inflammatory  products,  etc.  Conversely, 
it  is  admitted  that  animal  matter  may  form  the  nucleus  of  a  kidney  or 
pelvic  concretion,  while  a  bladder  calculus  may  also  be  formed  by  accre- 
tion of  the  purely  inorganic  elements  of  the  urine. 

A  calculus  is  rarely  of  uniform  composition,  more  frequently  com- 
bining two  or  more  inorganic  as  well  as  organic  elements  in  its  forma- 
tion. In  the  nomenclature  it  is  the  practice  to  give  to  the  stone  the  name 
of  the  preponderating  element. 

That  most  commonly  observed  is  composed  principally  of  uric  acid 
and  the  urates.  These  stones  are  of  fair  consistency,  yellowish  or 
light-brown  in  color,  not  very  smooth  when  single,  yet  not  so  rough 
as  oxalate-of-lime  concretions.  They  may  attain  a  diameter  of  two  or 
three  inches.  As  a  rule,  they  form  in  urine  which  is  distinctly  acid  in 
reaction. 

The  mulberry  or  oxalate-of-lime  calculus  is  next  in  order  of  fre- 
quency, and  relatively  more  so  in  children  than  in  adults.  They  may 
exist  in  all  sizes,  and  vary  greatly  in  color.  The  smaller  concretions  are 
light  in  color  and  fairly  smooth  ;  the  larger  are  exceedingly  rough,  with 
jagged  edges,  and  are  dark-brown  in  color,  in  rare  instances  white. 
Oxalate-of-lime  calculi  usually  commence  in  the  kidney,  and  pass  as 
small  particles  to  the  bladder.  The  most  severe  forms  of  "renal  colic" 
are  due  to  the  slow  and  painful  passage  of  these  rougher  concretions 
along  the  ureters. 

PhospJiatic  calculi  come  next  in  order  of  frequency,  and  are  divis- 
ible into  three  classes  :  the  ammonio-magnesian  and  phosp7iate-of-liine 
{fusible)  calculus,  neutral  pJiospJiate  of  lime,  and  ammonio-magnesian 
calculus. 

Fusible  calculi  are  more  often  met  with  than  the  other  two  forms  of 
phosphatic  concretions.  They  are  gray  or  white  in  color,  readily  friable, 
and  light.  The  hardness  is  proportionate  to  the  lime  phosj)hate  present. 
They  attain  large  size,  and  conform  themselves  to  the  shape  of  the 
bladder. 


STONE   IN   THE   BLADDER.  647 

The  neutral  pTiosphate-of-lime  calculus  is  rare.  It  may  form  in  the 
kidney,  though  it  originates  chiefly  in  the  bladder.  All  the  phosphatic 
calculi  are  chiefly  vesical  in  origin,  being  found  with  ammoniacal  urine, 
which  is  present  with  chronic  vesical  catarrh.  The  ammonio-iitagnesian 
phosphatic  concretion  is  equally  rare,  and  differs  very  slightly  in  its 
chemical  and  physical  characters  from  that  just  described. 

Other  and  still  rarer  forms  of  urinary  concretions  are  the  following : 

Qystin.—'Y\n&  variety  is  usually  smooth,  occasionally  corrugated, 
yellow  in  color  when  fresh,  inclining  to  a  greenish  hue  when  long 
removed.  They  break  readily,  do  not  show  a  marked  concentric  arrange- 
ment, and  are  somewhat  greasy  to  the  feel. 

Xanthic  or  uric-oxide  calculi  have  only  been  reported  in  two  or  three 
instances.  They  are  of  concentric  formation,  smooth  and  greasy  to  the 
feel,  and  vary  in  color  from  gray  to  brown. 

Carionate-of-Ume  calculi  are  usually  multiple,  and  are  light-gray  in 
color  and  chalky  in  consistence. 

Organic  calculi,  consisting  of  epithelia,  blood,  etc.,  are  not  infrequent 
as  nuclei  for  other  varieties,  but  exceedingly  rare  as  independent  forms. 

Stone  in  the  bladder  is  a  misfortune  that  may  befall  every  age  and 
condition  of  human  life,  from  the  foetus  in  utero,  to  the  old  and  decrepit. 
The  period  of  greatest  exemption  is  from  twenty  to  fifty  years  of  age. 
It  is  comparatively  frequent  in  children,  and  here  must  be  of  renal  origin 
and  due  to  the  excess  of  inorganic  elements  in  the  urine,  since  obstruc- 
tion and  inflammatory  diseases  of  the  urinary  tract  rarely  exist  at  this 
age.  After  fifty,  when  prostatic,  cystic,  and  urethral  obstruction  are  more 
frequently  met  with,  the  formation  of  calculi,  vesical  in  origin,  is  more 
common.  As  to  sex,  stone  is  more  frequent  in  males.  It  was  formerly 
argued  that  there  was  no  difference  in  the  frequency  of  stone  in  the 
sexes,  but  that  the  short  and  dilatable  urethra  of  the  female  allowed 
a  ready  escape  to  the  concretion  before  it  became  sufficiently  large  to 
produce  any  organic  disturbance.  When,  regardless  of  the  statisti- 
cal evidence  which  shows  that  the  number  of  deaths  in  males  from 
urinary  calculus  is  ten  times  greater  than  in  females,  we  consider  that 
one  of  the  most  frequent  causes  of  stone  is  the  gouty  diathesis,  and 
that  gout  is  more  frequent  in  men  ;  and,  again,  that  prostatic  and 
urethral  obstruction  is  peculiar  to  this  sex — it  must  be  conceded  that 
the  conditions  for  the  formation  of  calculi  are  more  frequently  present 
in  males. 

In  the  (Etiology  of  stone  in  the  bladder  two  great  factors  are  recog- 
nized :  The  one  includes  all  conditions  of  the  economy  which  favor  pre- 
cipitation of  the  inorganic  elements  of  the  urine  ;  the  second  all  ob- 
structive and  inflammatory  lesions  which  produce  decomposition  of  the 
urine  in  the  bladder,  the  detachment  of  epithelia,  and  the  accumulation 
of  other  organic  elements  which  serve  as  nuclei  around  which  the  salts 
of  the  urine  are  congregated. 

In  the  first  category  are  hereditary  tendencies,  such  as  gout  and  rheu- 
matism. Certain  conditions  of  mal-nutrition  undoubtedly  lead  to  a  pre- 
cipitation of  the  urinary  salts,  for  children  poorly  fed  and  cared  for  are 


648  A  TEXT-BOOK   ON   SURGERY. 

mucli  more  apt  to  suffer  from  calculus  than  those  wMcli  are  well  fed  and 
comfortably  clothed  and  sheltered. 

It  can  scarcely  be  doubted  that  residence  exercises  a  causative  influ- 
ence upon  the  formation  of  calculus.  In  the  United  States,  Northern 
Alabama,  Tennessee,  and  Kentucky  afford  a  large  number  of  this  class 
of  cases,  while  in  JSTew  York  and  the  New  England  States  stone  in  the 
bladder  is  exceedingly  rare. 

In  the  group  of  local  causes  may  be  classed  all  cystic  diseases  in 
which  the  products  of  inflammation  collect  in  the  bladder  and  form 
nuclei,  around  which  concretions  occur ;  prostatic  enlargement  induc- 
ing retention,  cystitis,  and  decomposition  of  urine ;  stricture,  and  all 
obstructive  and  inflammatory  lesions  of  the  urethra  which  may  involve 
or  affect  the  integrity  of  the  bladder ;  the  presence  of  any  foreign  matter 
in  the  bladder,  or  paralysis  of  the  bladder  from  any  cause. 

The  Syvipfoms  and  Diagnosis. — It  may  be  stated  at  once  that,  how- 
ever much  has  been  and  may  be  said  of  the  value  of  the  various  symptoms 
of  stone,  the  diagnosis  rests  upon  one  simple  expedient,  the  introduction 
of  a  metallic  instrument  into  the  bladder,  and  in  contact  with  the  stone. 
For  this  purpose  the  ordinary  steel  sound  is  nsually  sufficient.  The 
bladder  should  be  allowed  to  contain  about  half  a  pint  of  fluid,  and 
when  the  instrument  is  introduced  it  should  be  manipulated  so  that  the 
convexity  of  the  curve  will  glide  over  the  floor  of  the  bladder  back  and 
forth  from  the  neck  to  the  posterior  wall  of  the  organ,  at  the  same  time 
depressing  the  bladder  toward  the  rectum.  By  this  manoeuvre  the  stone 
will  be  induced  to  gravitate  to  the  deeper  portions  in  contact  with  the 
instrument,  or  so  close  to  it  that  a  sharp,  quick  turn  to  right  or  left  will 
bring  the  calculus  and  metal  into  appreciable  contact.  In  certain  cases 
of  prostatic  hypertrophy  the  calculus  may  remain  concealed  immediately 
behind  the  enlarged  organ,  and  in  such  a  position  that  the  sound  can  not 
be  brought  in  contact  with  it.  Under  such  conditions  Thompson's  searcher 
(Fig.  581)  will  be  found  useful.     The  objection  to  this  instrument  is  the 


Fig.  581. — Thompson's  searcher. 

diBBculty  of  its  introduction  from  the  abrupt  nature  of  the  curve  near  the 
tip.  When  once  introduced  its  value  is  readily  appreciated.  Turning 
its  point  downward  and  moving  as  if  to  withdraw  it,  there  is  no  portion 
of  the  floor  that  it  will  not  thoroughly  search. 

When  a  stone  can  not  be  appreciated  with  a  full  or  half-filled  bladder 
it  may  be  felt  if  this  organ  is  completely  emptied.  Not  only  is  the  cal- 
culus di'iven  toward  the  neck  of  the  bladder  when  it  is  emptied  of  urine, 
but  the  hardness  and  weight  are  more  readily  appreciated,  since  it  is 
held  in  the  grasp  of  the  organ,  and  can  not  slip  away  when  the  sound 
touches  it.  In  some  forms  of  vesical  calculus  the  stone  becomes  partially 
or  completely  encysted  in  some  portion  of  the  bladder- wall.  The  calculus 
may  drop  into  an  abnormal  pouch  in  the  bladder  ;  it  may  sink  by  a  pro- 


STONE   IX   THE   BLADDER.  649 

cess  of  ulceration  into  the  walls,  and  be  partially  or  completely  sur- 
ronnded  by  a  newly  fonned  inflammatory  tissne,  or  it  may  have  been 
lodged  in  the  nreter  near  its  termination. 

Again,  a  stone  may  be  caught  in  the  upper  portion  of  the  bladder 
without  being  sacculated.  In  sounding  for  stone  in  adults,  ether  narcosis 
is  not  always  required,  especially  where  there  are  no  symptoms  of  severe 
cystitis  and  tenesmus.  In  children  an  ansesthetic  should  always  be  em- 
ployed. A\^hen  the  calculus  can  not  be  felt  after  careful  search,  it  is  at 
times  a  successful  expedient  to  introduce  the  finger  into  the  rectum  and 
make  upward  pressure  uj)on  the  base  of  the  bladder,  and  firm  pressure 
downward  upon  the  abdomen,  just  above  the  symphysis  pubis. 

Vesical  calculus  may  be  suspected  in  a  patient  who  has  had  renal 
colic,  or  has  passed  by  the  urethra  particles  of  gravel,  and  afterward 
develops  a  cystitis.  ]N"ot  infrequently,  however,  a  concretion  goes  from 
the  kidney  into  the  bladder  without  attracting  the  attention  of  the 
patient.  If  it  lodges  here,  and  increases  slowly  in  size,  it  may  remain 
for  months  or  years  without  giving  any  symptoms  of  cystitis,  or  marked 
annoyance.  Usually,  however,  when  a  stone  is  present,  and  is  so  light 
and  smooth  that  it  does  not  affect  the  mucous  membrane  of  the  bladder, 
it  attracts  attention  by  mechanical  interference  -nith  the  escape  of  urine, 
dropping  at  times  into  the  orifice  of  the  urethi'a,  and  suddenly  shutting 
off  the  flow  during  micturition. 

When  a  stone,  by  reason  of  its  size,  weight,  and  roughness,  begins  to 
cause  cystitis,  freqiient  micturition  is  a  prominent  symptom.  A  burning 
or  smarting  pain,  referred  to  the  end  of  the  penis,  is  a  frequent  symptom 
in  this,  as  in  idiopathic  inflammation  of  this  organ.  At  times  the  pain 
is  referred  to  the  scrotum,  penis,  uterus,  and  other  organs,  or  along  the 
nerve-tracts  in  the  lower  extremities.  In  any  jolting  movement,  as  in 
riding  on  horseback,  or  in  vehicles  without  springs,  or  in  walking  about, 
the  pain  is  increased.  Tenesmus  is  often  violent  toward  the  end  of  urina- 
rion,  when  the  stone  is  grasped  by  the  contracting  bladder.  The  urine 
almost  always  contains  pus,  and  blood  is  frequently  present.  Hfematuria, 
with  calculus,  occurs  chiefly  during  the  waking  hours,  when  the  patient 
is  moving  about.  It  is  more  apt  to  be  met  with  in  oxalate- of -lime  calculi 
than  in  the  other  varieties.  In  the  rare  instances  in  which  stone  exists 
with  villous  growths  of  the  bladder,  hfemorrhage  is  often  excessive. 
When  a  calculus  is  of  large  size,  it  may  by  pressure  produce  pain  and 
symptoms  of  disturbance  in  other  organs,  as  the  vagina,  uterus,  or  rec- 
tum. The  size  and  character  of  a  stone  in  the  bladder  may,  in  a  measui-e, 
be  determined  by  exi^loration  with  the  sound,  as  well  as  by  palpation. 

A  large  stone  is  usually  felt  as  soon  as  the  sound  enters  the  neck  of 
the  bladder.  The  sense  of  resistance  is  greater,  and  a  fair  idea  of  its 
proportions  may  be  made  out  by  passing  the  metallic  sound  along  its 
surfaces.  A  small  stone  is  often  with  difficulty  recognized.  Pressure 
above  the  symphysis  pubis,  and  intra-vaginal  or  rectal  exploration,  are 
not  without  value  in  estynating  the  size  of  a  calculus.  If  the  click  of  the 
sound  is  sharp  and  clear,  and  if  the  surface  is  rough  and  grating  to  the 
sense  of*  touch  conveyed  along  the  instrument,  an  oxalate-of-lime  stone 


650  A  TEXT-BOOK   ON  SURGERY. 

may  be  suspected,  and,  if  the  patient  is  a  cLild,  the  suspicion  is  strength- 
ened. Hfematuria,  and  all  the  symptoms  of  cystitis,  are,  as  a  rule,  in- 
creased with  this  form  of  calculus.  In  patients  with  the  gouty  or  rheu- 
matic diathesis,  uric-acid  stone  is  the  rule.  The  acidity  of  the  urine  in 
a  measure  excludes  phosphatic  calculus.  In  the  exceptional  instances  in 
which  a  portion  of  the  surface  of  the  bladder  has  become  incrusted  with 
the  inorganic  elements  of  the  urine,  this  condition  may  be  determined  by 
the  immobility  of  the  concretion  when  the  sound  is  brought  in  contact 
with  it.  The  absence  of  a  spherical  calculus  can  be  determined  by  digital 
exploration  through  the  rectum  or  vagina,  combined  with  pressure  from 
above  the  symphysis  pubis. 

Treatment  and  Prognosis. — The  attempts  to  dissolve  vesical  calculi 
by  the  administration  of  remedies  by  the  mouth,  or  by  solutions  thrown 
into  the  bladder,  have  not  met  with  encouraging  success.  While  there 
is  little  doubt  that  the  correction  of  a  dyscrasia  which  is  favorable  to  the 
formation  of  stone  may  prevent  or  retard  the  further  growth  of  an  ex- 
isting concretion,  there  is  no  evidence  to  prove  that  a  stone  in  the  blad- 
der was  ever  removed  by  this  plan  of  treatment. 

The  projDer  treatment  of  stone  in  the  bladder  may  be  divided  into  the 
curative  and  palliative.  To  the  former  belong  the  operations  of  litTiot- 
omy  and  litliotrity ;  to  the  latter  are  systematic  medication  and  hy- 
giene, together  with  the  employment  of  all  local  means  calculated  to 
relieve  pain  and  prolong  life.  In  determining  upon  the  proper  method 
to  be  adopted,  the  following  jDoints  should  be  duly  considered  : 

In  male  patients  under  the  age  of  seventeen  the  cutting  oiDeration  is 
preferable,  for  the  reasons  that  (1)  the  caliber  of  the  urethra  is  usually 
too  small  to  admit  of  the  instrumentation  necessary  to  lithotrity  ;  (2)  the 
mortality  rate  after  lithotomy  in  this  class  of  patients  is  very  low — about 
5  per  cent.  After  this  period,  as  between  lithotomy  and  Lithotrity,  the 
former  operation  is  demanded  (1)  in  all  cases  of  stricture  of  the  urethra, 
where  the  caliber  of  this  tube  is  narrowed  to  such  an  extent  that  the  re- 
peated introduction  of  the  lithotrite  and  washing-apparatus  is  difficult  or 
impossible  ;  (2)  in  prostatic  disease,  with  hypertrophy  to  such  an  extent 
that  it  offers  an  impediment  to  the  introduction  of  the  instruments,  aiad 
renders  the  seizure  of  the  stone  or  fragments  difficult  of  accomplishment ; 
(3)  when  the  stone  is  more  than  one  inch  in  diameter ;  (4)  when  it  is  so 
hard  (oxalate  of  lime)  that  it  can  not  be  crushed  by  the  employment  of  a 
reasonable  degree  of  force  ;  (5)  when  chronic  cystitis  and  vesical  intoler- 
ance exist ;  (6)  in  a  j^atient  suffering  from  any  form  of  nephritis. 

Litliotrity. — If  the  symptoms  are  not  so  distressing  as  to  demand 
immediate  interference,  from  ten  days  to  two  weeks  should  be  devoted 
to  the  careful  preparation  of  the  patient.  It  is  not  only  important  to 
improve  the  general  condition,  but  also  to  accustom  the  urethra  to  the 
introduction  of  the  sound. 

The  instruments  required  are  the  lithotrite  and  an  apparatus  for  wash- 
ing out  the  detritus. 

Of  the  various  crushing-instruments  which  have  been  introduced,  that 
of  Sir  Henry  Thompson  is  to  be  preferred  (Figs.  582-585).     It-  is  com- 


STONE   IN   THE   BLADDER— LITHOTRITY. 


651 


mendable  for  its  lightness,  strength,    and   smooth   action.      With  the 
heavier  instruments  the  sense  of  touch  is  not  so  delicate  and  acute.     The 

lighter  lithotrite  is  strong  enough 
to  crush  any  calculus  which  may 
be  safely  removed  by  this  opera- 
tion. Moreover,  it  is  especially 
to  be  commended  for  the  fenes- 
trated jaw  in  the  female  blade 
(Fig.  582),  which  allows  the  male 
blade  to  pass  entirely  through, 

Fia.  582.-Fenestratcd  jaws  of  Thompson's  lithotrite.       and    thuS    avoids     the    danger    of 

choking  and  fouling.  It  consists 
of  a  male  blade  (Fig.  583),  or  sliding  rod,  which  fits  into  a  fixed  or  female 
blade  (Fig.  584),  which  is  deeply  hollowed  out  for  its  reception. 


G.TIEMANN-CO. 


Fig.  584. — Female  Made  of  Thompson's  lithotrite. 

The  seizing  and  crushing  action  of  the  lithotrite  is  double.  When  the 
male  blade  is  carried  through  the  hollow  handle  into  the  slot  in  the  female 
blade,  a  simple  and  rapid  to-and-fro  movement  can  be  executed  by  push- 
ing or  pulling  on  the  male  blade  with  the  right  hand,  while  the  left 


Fig.  585. — Thompson's  lithotrite  adjusted. 

steadies  the  female  blade,  to  which  the  handle  is  attached.  This  move- 
ment can  be  made  very  eifective  in  seizing  the  stone  and  in  crushing  the 
smaller  fragments  without  taking  the  extra  time  in  sliding  the  catch 
which  throws  on  the  screw-motion  of  the  instrument. 

When,  however,  a  stone  is  caught  in  its  grasp  by  the  sliding  move- 
ment just  described,  and  is  so  solid  and  resisting  that  a  sufficient  and  safe 
crushing  force  can  not  be  employed,  the  catch  on  the  top  of  the  handle  is 
slipped  upward.  The  sliding  movement  is  now  impossible,  and  the  more 
powerful  screw-motion  substituted.  By  turning  the  wheel  at  the  end  of 
the  male  blade  to  the  right,  the  stone  can  be  felt  to  give  way  under  the 
crushing  force. 

In  the  removal  of  vesical  calculi  by  this  operation  two  procedures  are 
recognized,  viz.,  complete  and  incoinplete  lithotrity. 

In  the  former,  or  Bigelow's  method,  ether  narcosis  is  required  ;  the 
stone  is  entirely  crushed,   and  the  fragments  washed  out  at  a  single 


652  A  TEXT-BOOK   ON  SITEGERY. 

operation.  In  the  latter,  anaesthesia  is  not  employed  ;  the  calculus  is 
only  partially  comminuted,  and  the  fragments  are  left  to  pass  off  with 
the  urine. 

Complete  lithotrity  has  almost  entirely  superseded  the  older  operation. 
It  is  preferable  in  all  cases  where  the  condition  of  the  patient  justifies  the 
risk  of  shock  from  a  capital  operation  under  ether  narcosis. 

Operation. — The  patient,  being  narcotized,  is  placed  upon  the  operat- 
ing-table, in  the  dorsal  decubitus,  with  the  pelvis  raised  about  half  a  foot, 
by  pillows  placed  under  the  sacrum.  If  the  bladder  has  not  been  emptied 
just  before  the  operation,  the  urine  is  now  drawn  off  and  about  one  pint 
of  tepid  water  injected,  thus  distending  this  organ  and  rendering  the 
mucous  membrane  less  liable  to  injury  from  being  picked  up  by  the  in- 
strument. The  lithotrite,  having  been  properly  warmed,  oiled,  and  tested 
as  to  its  working  capacity  and  strength,  is  now  prepared  for  introduction, 
by  sliding  the  male  blade  completely  down  untU  its  tip  passes  into  the 
fenestra  of  the  female  blade.  As  the  convexity  of  the  male  blade  is 
serrated,  great  care  must  be  taken  not  to  push  the  rough  surface  beyond 
the  level  of  the  female  blade,  since  the  introduction  of  the  instrument, 
improperly  adjusted,  would  do  unnecessary  violence  to  the  floor  of  the 
urethra. 

A  right-handed  operator  should  stand  at  the  patient's  right  side.  Tlie 
instrument  is  locked.and  carried  into  the  bladder  by  the  same  manoeuvres 
as  given  for  the  introduction  of  the  sound  or  metal  catheter.  When  the 
beak  is  well  into  the  bladder,  it  is  carried  along  the  floor,  with  the  tip 
pointing  upward,  until  it  meets  with  the  resistance  of  the  posterior  wall 
of  the  bladder,  when  it  should  be  slightly  withdrawn.  The  handle  should 
now  be  elevated,  in  order  to  depress  the  floor  of  the  bladder  with  the  con- 
vexity of  the  curve.  Held  firmly  in  this  position,  the  lithotrite  is  opened 
by  withdrawing  the  male  blade  about  two  inches.  The  operator  should 
now  strike  the  handle  of  the  instrument  with  the  knuckles  or  hand, 
hard  enough  to  carry  the  concussion  to  the  bladder,  in  order  to  dislodge 
the  calculus  and  allow  it  to  fall  into  the  lowest  portion  of  the  organ,  and 
within  the  grasp  of  the  lithotrite,  which  is  now  closed  by  pushing  the 
male  blade  down.  If  the  stone  is  seized,  it  will  be  made  evident  by  the 
failure  to  close  the  blades,  and,  when  caught,  it  should  be  firmly  held, 
the  screw-movement  adjusted,  and  the  wheel  rotated  slowly.  Having 
thus  secured  the  stone,  the  instrument  should  be  moved  to  and  fro,  in 
order  to  assure  the  operator  that  the  wall  of  the  bladder  is  not  caught. 
In  crushing  a  calculus,  the  rapidity  with  which  it  is  done  should  be  de- 
termined by  the  sense  of  resistance  experienced.  It  is  not  safe  to  employ 
force  sufficient  to  spring  the  blades.  A  stone  which  can  be  safely  crushed 
will  yield  perceptibly  under  a  few  turns  of  the  screw.  Phosphatic  stone 
can  often  be  rapidly  comminxTted  without  adjusting  the  screw.  Uric-acid 
calculi  require  more  power,  while  the  oxalate-of-lime  at  times  can  not  be 
crushed  at  all. 

If  the  manoeuvre  above  described  fails  after  being  several  times  care- 
fully repeated,  search  must  be  made  in  other  qiiarters.  Holding  the 
instrument  beak  upward,  the  convexity  still  upon  the  floor  of  the  blad- 


STONE   IN   THE   BLADDER— LITHOTRITY. 


653 


der,  separate  the  blades,  turn  the  shaft  half  over  to  the  right,  and  then 
close  the  blades.  If  the  stone  is  seized,  hold  it  steady,  adjust  the  screw- 
motion,  tighten  the  grip  by  a  slight  turn  of  the  wheel,  and  carry  the 
instrument  back  to  the  middle  line  with  the  beak  pointing  upward.  If 
it  does  not  move  freely,  the  indication  is  that  the  bladder  has  been  picked 
up,  and  of  course  the  blades  must  be  separated  and  another  effort  made. 
With  the  instrument  shown  there  is  little  danger  of  this  accident.  The 
same  manoeuvre  may  be  tried  on  the  opposite  side.  If  there  is  prostatic 
enlargement,  it  may  be  necessary  to  turn  the  beak  downward  into  the 
pocket  on  the  floor  of  the  bladder.  If,  after  a  half-hour's  search,  the 
seizure  has  not  been  effected,  the  operation  should  be  discontinued. 

When  the  stone  has  been  seized  and  broken  once,  the  same  manoeuvres 
should  be  carefully  yet  rapidly  repeated  until  no  large  pieces  remain. 
It  will  usually  be  found  easy  to  crush  the  smaller  pieces  by  the  sliding 
movement  alone.  The  instrument  should 
now  be  closed  until  the  blades  have  the 
same  relation  as  when  introduced,  and  then 
withdrawn.  The  evacuator  consists  of  a 
rubber  bulb  capable  of  holding  about  one 
pint.  At  the  upper  end  is  a  funnel  and 
stop-cock  for  filling  and  closing  the  appa- 
ratus. Below  is  attached  a  glass  globe,  in 
which  the  particles  of  stone  gravitate  as 
fast  as  they  are  drawn  into  the  evacuator. 
Between  this  and  the  rubber  bulb  is  a  sec- 
ond stop-cock,  and  a  place  for  attaching  the 
catheter.  It  is  advisable  to  insert  a  piece 
of  rubber  tubing,  about  five  inches  in  length, 
between  the  catheter  and  the  evacuator,  in 
order  to  prevent  the  jarring  motion  impart- 
ed to  the  bulb  from  being  conveyed  to  the 
instrument  in  the  bladder.  The  catheters 
(Fig.  586)  are  of  different  sizes  and  shapes, 
ranging  from  No.  14  to  No.  25,  U.  S.  The 
evacuation  is  much  more  rapid  with  the 
larger  instruments.  However,  the  urethra 
should  not  be  over-distended.  In  general, 
the  catheters  which  are  only  slightly  curved  near  the  tip,  with  the  eye 
at  the  extremity,  are  preferable.  In  filling  the  bulb,  in  order  to  exclude 
the  air,  the  glass  ball  is  first  detached,  filled  with  clean  warm  water, 
and  readjusted.  Both  stop-cocks  are  now  opened,  the  end  of  the  tube 
closed  with  the  finger,  and  water  poured  into  the  funnel  until  the  bulb 
and  tube  are  filled  to  overflowing.  The  cocks  are  then  closed,  and  the 
instrument  intrusted  to  an  assistant.  The  catheter,  well  oiled,  is  car- 
ried into  the  bladder,  and  as  the  water  is  escaping  the  lower  end  of  the 
rubber  tube  attached  to  the  evac^^ator  is  slipped  over  the  end  of  the 
instrument.  The  bulb  is  grasped  between  the  thumbs  and  fingers  of 
both  hands  and  squeezed,  thus  forcing  the  greater  part  of  its  contents 


Fio.  580. — Thompson's  improved  evacu- 
ator and  catheters. 


654  A  TEXT-BOOK   ON  SURGERY. 

into  the  bladder.  It  is  now  allowed  to  expand,  the  water  rushes  back 
out  of  the  bladder  and  brings  with  it  the  smaller  particles  of  stone  which 
fall  down  into  the  glass  sphere.  This  part  of  the  operation  may  be 
expedited  by  rapidly  half  emptying  the  bulb  into  the  bladder,  and  as 
rapidly  allowing  it  to  expand.  When  it  is  seen  that  particles  of  the 
calculus  cease  to  fall  into  the  receiver,  the  catheter  should  be  withdrawn, 
the  lithotrite  reintroduced,  and  a  second  crushing  done.  The  bladder  is 
again  washed  ont,  and  these  operations  should  be  alternated  untU  all 
detritus  is  removed,  unless  alarming  symptoms  should  supervene,  when 
of  course  all  operative  measures  should  be  discontinued.  If  the  glass 
receiver  becomes  filled,  it  should  be  detached  and  emptied.  At  times 
particles  of  calculus  become  lodged  in  the  catheter  or  tube,  and  require 
to  be  dislodged  with  a  stylet.  From  one  to  two  hours  may  be  allowed 
for  this  operation  from  the  commencement  of  the  anaesthesia.  The  prog- 
nosis will  be  more  favorable  with  the  shorter  period,  but  it  is  wiser  to 
proceed  carefully  and  remove  the  stone  thoroughly,  even  if  a  longer  time 
is  required.  The  absence  of  all  fragments  can  be  recognized  by  placing 
the  ear  over  the  bladder  at  the  symphysis  while  the  evacuator  is  being 
worked.  The  click  of  any  fragments  against  the  catheter  can  be  dis- 
tinctly heard.  The  introduction  of  a  sound  will  also  determine  the 
presence  of  any  pieces. 

In  the  after-treatment  opium  is  essential  to  relieve  pain  and  tenesmus. 
Citrate  of  potash,  grs.  xx,  three  or  four  times  a  day,  with  fiaxseed-tea, 
will  render  the  urine  less  irritating.  The  soft  catheter  may  need  to  be 
employed  to  evacuate  the  bladder. 

In  incomplete  lithotrity  the  crushing  is  done  in  the  same  manner  as 
just  described.  A  fair  degree  of  ansesthesia  may  be  secured  by  the  em- 
ployment of  cocaine.  The  lithotrite  is  only  introduced  once,  and  not 
more  than  five  or  ten  minutes  are  consumed  in  the  operation.  The 
evacuator  is  not  employed,  the  detritus  being  expelled  in  the  act  of 
urination. 

Cystotomy  or  Lithotomy. — Cutting  into  the  bladder  for  the  removal 
of  stone  is  performed  through  the  perinseum  or  through  the  abdominal 
wall,  just  above  the  symphysis  pubis.  Incision  through  the  rectum  in 
males  is  no  longer  a  recognized  procedure,  while  the  vesico-vaginal  opera- 
tion is  rarely  indicated. 

Supra-pubic  cystotomy,  or  the  JiigTi  operation  (as  distingxiished  from 
perineal  cystotomy),  is  performed  as  follows  : 

The  pubes  should  be  shaved  and  thoroughly  disinfected,  the  pelvis 
raised  on  a  cushion  so  that  the  intestines  will  gravitate  toward  the  dia- 
phragm. The  bladder  should  be  several  times  washed  out  with  warm 
Thiersch's  solution,  or  a  solution  of  boracic  acid,  grs.  v  to  water  f  j, 
throwing  about  eight  to  ten  ounces  in  through  a  soft  catheter  and  allow- 
ing it  to  escape.  A  rectal  bag  or  Barnes' s  dilator  should  now  be  well  lubri- 
cated and  pushed  into  the  rectum  and  distended  with  six  ounces  of  water. 
From  eight  to  twelve  ounces  of  warm  Thiersch  solution  should  then  be 
forced  into  the  bladder,  the  catheter  withdrawn  and  a  ligature  imme- 
diately tied  around  the  penis  to  prevent  escape  of  the  liquid.    In  females 


STONE  IN   THE  BLADDER— LITHOTOMY.  655 

the  urethra  may  be  plugged.  These  two  procedures  lift  the  bladder 
upward,  render  it  tense,  and  aid  in  displacing  upward  the  fold  of  peii- 
tonfeum  which  drops  down  in  front  of  the  anterior  wall  of  the  bladder. 

An  incision  in  the  linea  alba,  extending  from  three  inches  above  the 
symphysis  to  one  half  an  inch  below  the  upper  margin  of  the  pubic 
bones,  is  next  made,  and  the  tissues  separated  in  the  median  line  until 
the  layer  of  fat  which  lies  between  the  bladder- wall  and  the  pubes  is  in 
sight.  It  is  always  advisable  to  snip  with  the  scissors  a  half-inch  of  the 
attachment  of  the  muscles  to  the  pubes  on  either  side  of  the  wound. 
All  bleeding  should  be  arrested  and  this  prevesical  areolar  tissue  lifted 
upward  by  the  finger-nail  or  a  dry  dissector.  Should  the  peritonasum 
dip  down  low,  it  will  be  lifted  by  this  manoeuvre.  A  dull  retractor 
placed  beneath  this  tissue  and  traction  made  toward  the  umbilicus 
should  now  be  used,  and  two  similar  instruments  to  separate  the  wound 
laterally.  The  anterior  wall  of  the  distended  bladder  is  now  in  plain 
view  for  about  two  inches  in  its  long  axis.  Occasionally  at  this  step  of 
the  operation  one  or  two  good-sized  veins  are  seen  crossing  the  proposed 
line  of  incision  in  the  bladder.  These  should  be  secured  by  passing  a 
curved  needle  armed  with  catgut  a'round  them  and  tying  on  each  side  of 
the  line  of  incision. 

The  next  step  is  to  introduce  into  the  wall  of  the  bladder,  on  each  side 
of  the  line  of  the  incision  about  to  be  made,  a  loop  of  small  Chinese 
twisted  silk.  This  may  be  done  by  means  of  a  curved  needle,  leaving 
the  thread  double  and  tying  it  in  a  long  loof),  so  that  it  maj'  be  removed 
in  three  or  four  days  without  disturbing  the  wound. 

These  threads  are  now  held  steady,  the  operator  makes  out  distinctly 
the  spot  where  he  proposes  to  puncture,  and,  carrying  the  knife  through, 
back  of  the  blade  downward,  he  enters  the  bladder  a  little  below  the 
level  of  the  pubic  rim  and  cuts  upward  about  one  inch  exactly  in  the 
long  axis  of  the  organ.  The  water  rushes  out  at  once,  and  the  finger  is 
carried  into  the  bladder,  traction  being  made  on  the  threads  to  prevent 
the  separation  of  the  wall  of  the  bladder  from  the  fascia  in  front.  This 
is  of  gTeat  importance  in  preventing  the  occurrence  of  an  obstinate 
pocket  or  fistula  which  not  infrequently  follows  this  operation. 

If  the  operation  is  for  stone  or  a  foreign  iody,  the  removal  may  be 
effected  either  with  the  finger  or  a  delicate  dressing  forceps.  The  open- 
ing may  be  stretched,  if  required,  or  enlarged  by  incision.  If  a  tumor  is 
present,  it  will  usually  require  a  freer  incision  through  the  abdominal 
wall  in  order  to  thoroughly  inspect  the  bladder,  or  to  apply  the  cautery 
to  the  pedicle  of  any  neoplasm  which  may  be  removed.  To  accomi^lish 
this,  a  transverse  incision  just  at  the  level  of  the  pubes  should  be  made, 
extending  to  either  side  of  the  median  line  one  and  a  half  to  two  inches. 
The  attachments  of  the  recti  muscles  are  divided,  but  care  should  be 
taken  not  to  extend  the  incision  far  enough  laterally  to  divide  the  inter- 
nal pillar  of  the  ingninal  canal.  The  long  retractors  now  inserted  into 
the  bladder  will  stretch  the  opening  and  allow  a  free  inspection  of  the 
entire  inner  surface.  When  the  light  is  not  good,  the  electric  arc  will  be 
of  great  service  in  illuminating  the  interior  of  this  organ. 


656 


A  TEXT-BOOK  ON   SUKGERY. 


The  detachment  of  tumors  may  be  effected  with  a  Volkmann's  spoon, 
or  better  with  the  Spencer  Wells  fenestrated  ovarian  sac  forceps.  When 
thus  torn,  cut,  or  twisted  off  to  the  level  of  the  bladder- wall,  the  point 
of  attachment  should  be  carefully  seared  with  the  cautery. 

The  after-treatment  of  supra-pubic  cystotomy  will  depend  upon  the 
condition  of  the  bladder  at  the  time  of  and  immediately  after  the 
operation. 

If  there  is  a  chronic  cystitis,  or  if  a  neoplasm  has  been  removed  and 
bleeding  can  not  be  altogether  arrested,  drainage  is  indicated.  If  the 
bladder  is  not  inflamed,  it  should  be  sutured  at  once. 

Drainage  is  secured  by  inserting  a  Trendelenberg's  soft  rubber  T- 
shaped  tube  (Fig.  586  a).  The  ends  of  the  cross-piece  should  be  folded 
back,  grasped  in  the  jaws  of  a  delicate  dressing 
forceps,  and,  while  the  bladder  is  firmly  fixed  by 
traction  on  the  threads,  the  tube  is  carried  to  the 
floor  of  this  organ.  As  the  forceps  open,  the 
cross-j)iece  expands  and  prevents  the  easy  with- 
drawal of  the  tube.  After  thorough  irrigation, 
the  wound  around  the  tube  should  be  closely 
packed  with  long  ribbons  of  iodoform  gauze,  and 
over  this  sublimate  or  carbolic-gauze  protective 
and  a  bandage. 

The  patient  is  put  to  bed,  resting  on  the  side. 
By  means  of  a  piece  of  glass  tubing,  a  long  rubber 
tube  is  connected  to  the  end  of  the  T-drain,  and 
this  channel  conducts  the  urine,  as  fast  as  it  en- 
ters the  bladder,  into  a  vessel  at  the  bedside.  Irri- 
gation with  warm  Thiersch  solution  should  be 
made  every  three  or  four  hours  for  the  first  two 
days,  and  every  six  hours  for  two  more  days,  or 
until  the  discharge  is  clean.  This  is  accomplished 
by  uncoupling  the  glass  pipette  and  injecting 
through  the  T-drain  two  to  four  or  six  ounces, 
and  allowing  it  to  escape  at  once  through  the  tube.  The  tube  should 
be  removed  as  soon  as  the  condition  of  the  bladder  will  permit,  be- 
cause the  longer  it  is  allowed  to  remain  the  greater  the  danger  of  a 
troublesome  persisting  fistula.  Four  to  eight  days  will  be  the  limit  in 
most  cases.  Of  course,  in  bad  cases  of  cystitis,  drainage  must  be  kept 
up  until  the  disease  is  cured,  if  this  takes  weeks  or  months.  The  urine 
escapes  through  the  tube  and  then  through  the  wound  until  this  begins 
to  be  narrowed  by  granulation.  The  dressing  is  continued  until  cicatri- 
zation is  complete.  When  pockets  form,  they  must  be  opened  ujj, 
scraped,  and  packed.  When  fistula  persists,  it  may  have  to  be  split  up 
and  scraped.  In  two  instances  I  have  had  to  dissect  out  the  indurated 
tissues  and  again  open  into  the  bladder  to  effect  a  cure  of  fistulse. 

When  the  bladder  is  to  be  closed  at  once,  proceed  as  follows  :  Irri- 
gate thoroughly  and  pull  the  edges  of  the  incision  in  the  bladder- wall  as 
well  up  into  the  wound  as  possible.     A  half-curved  needle  armed  with 


Fio.  586  a. 

T-tube,   for  drainage  after 

supni-pubic  cystotomy. 


STONE  IN   THE   BLADDER— LITHOTOMY.  657 

fine  catgut,  should  now  be  introduced  about  one  eigbtli  inch  from  the 
edge  of  the  incision  in  the  bladder,  and  carried  through  and  out  on  the 
cut  edge  jast  where  the  mucous  membrane  rests  on  the  bladder-muscle 
(not  into  the  cavity).  It  should  be  made  to  enter  at  the  same  level 
on  the  opposite  side  and  to  come  out  one  eighth  of  an  inch  from  the 
edge.  These  sutures  should  be  about  one  eighth  to  three  sixteenths 
of  an  inch  apart,  and  when  tied  should  be  cut  off  short.  The  abdom- 
inal wound  may  now  be  closed  in  part  from  the  ends,  but  not  over  the 
line  of  sutures  in  the  bladder.  Light  iodoform  gauze  packing  should 
fill  in  the  opening,  and  a  sublimate  gauze  dressing  over  all.  The  patient 
should  rest  on  the  back,  and  the  urine  allowed  to  flow  out  constantly 
through  a  soft  catheter,  fastened  in  through  the  urethra.  Should  dis- 
tention occur,  urine  would  very  probably  escape  through  the  wound.  In 
any  event,  as  the  abdominal  wound  is  open,  there  is  no  danger  should 
leakage  happen. 

To  tliis  date  (January  1,  1890)  the  author's  experience  in  suprapubic 
cystotomy  is  included  in  the  following  synopsis  of  cases : 

Case  I. — Male,  aged  40.  Operation,  Jnly  7,  1888.  Seven  months  before,  liBBmaturia,  chills, 
and  fever.  Diagnosis,  cancer  of  bladder.  Operation,  large  epithelioma  removed.  Ordinary 
T-drainage  tube;  removed  eighth  day.  Urine  ceased  to  escape  through  wound  sisteenth  day. 
Eecovery.     Six  months  later,  death  from  general  metastasis  and  exhaustion. 

Case  II. — Male,  aged  36.  Operation,  July  20,  1888.  Small  sessile  tumor  removed  from 
floor  of  bladder.     Tube  removed  sixth  day.     Wound  had  closed  eighteenth  day.     Recovered. 

Case  III. — Female,  aged  20.  Tumor  of  urethra  growing  back  into  bladder.  Operation, 
March  26,  1889.  "Wound  in  bladder  closed  with  catgut.  Cathether  worn  for  ten  days. 
Eecovered. 

Case  IV. — Male,  aged  67.  Operation,  September  4,  1888.  Tumor  of  prostate  and  vesical, 
calculus  removed.  Drainage-tube  removed  sixth  day.  Wound  had  closed  fifteenth  day. 
Eecovered. 

Case  V. — Male,  aged  46.  Operation,  September  28,  1888.  Large  stone  removed.  Tube 
discontinued  eighth  day.  Fistula  persisted  four  weeks ;  later  this  was  scraped  out,  and  it  then 
closed.     Eecovered. 

Case  VI. — Male,  aged  41.  Operation,  July  25,  1888.  Piece  of  catheter  removed.  Tube 
discontinued  tifth  day.     Wound  healed  by  fourteenth  day.     Recovered. 

Case  VII. — Male,  aged  40.  Operation,  December,  1888,  for  chronic  cystitis.  Drained  for 
three  weeks.     Recovered. 

Case  VIIL— Male,  aged  68.  Operation,  September  2,  1888,  for  closure  of  fistula,  which 
was  easily  cured.     Recovered. 

Case  IX. — Male,  aged  48.  Operation,  September,  1889.  Tumor  of  prostate  and  vesical 
calculus  removed.     Drainage.     Eecovered. 

Cases  X  and  XL— Male,  aged  54.  Operation,  October,  1889.  Tumor  of  bladder  Just 
behind  urethral  opening  removed.  Drainage  removed  eighth  day,  and  wound  healed.  Cys- 
titis, with  alarming  elevation  of  temperature,  recurred  in  this  case,  and  three  weeks  later  a 
second  operation  without  anaesthesia  was  done.     Eecovered. 

Cases  XII  and  XIII. — Male,  aged  4.  Severe  cystitis,  with  paralysis  of  bladder,  due  to 
compression  myelitis.  Tube  removed  on  the  fourteenth  day.  The  cystitis  recurred,  and 
the  operation  was  repeated.     Drainage-tube  still  in  position.     Eecovered. 

Case  XIV.— Female,  aged  43.  Operation,  December,  1889.  Valvular  fold  of  hypertro- 
phied  mucous  membrane  stretched  partially  over  exit  of  urethra.  Eemoved.  Wound  in  blad- 
der closed  at  once.     Eecovered. 

Case  XV. — Male,  aged  60.     Operation,  December,  1889.     Piece  of  catheter  four  inches 
long,  incrusted  with  stone,  removed.     Drainage  tube  discontinued  on  fifth  day.     Recovered. 
42 


658  A  TEXT-BOOK  ON  SURGERY. 

Supra-pubic  cystotomy  has,  at  various  times  in  the  history  of  surgery, 
been  brought  prominently  before  the  profession,  but  to  achieve  a  short- 
lived popularity,  and  be  relegated  to  comparative  obscurity. 

Under  the  impulse  of  modern  aseptic  practice  and  an  improved  tech- 
nique, it  has  gained  a  position  not  heretofore  accorded  it,  and  it  is  safe 
to  say  from  which  it  will  not  again  recede. 

To  'perineal  cystotomy  it  should  be  preferred — 1.  For  the  I'emoval  of 
all  forms  of  neoplasms.  2.  For  the  removal  of  foreign  bodies,  so  shaped 
or  so  large  that  they  can  not  be  withdrawn  by  means  of  the  lithotrite. 
3.  For  stone,  when,  (a)  by  reason  of  urethral  or  prostatic  lesions,  the 
lithotrite  and  washing- tubes  can  not  be  freely  and  safely  employed ; 
(5)  when,  from  chronic  prostatitis,  great  hypertrophy  of  this  organ  with 
elongation  of  the  neck  of  the  bladder  has  occurred,  rendering  the  cal- 
culus difficult  of  access  by  this  roiite  ;  (c)  when  a  stone  so  hard  or  so 
large  that  it  can  not  be  rapidly  comminuted  and  removed  by  the  litho- 
trite ;  {d')  v/hen  vesical  calculus  is  complicated  with  chronic  nephritis. 

While  it  is  difficult  to  specify  the  exact  size  of  a  stone  to  be  removed 
by  the  high  operation,  it  would  be  safe  to  include  those  the  smallest 
diameter  of  which  would  measure  more  than  one  inch. 

In  adult  males  under  fifteen,  on  account  of  the  distensibility  of  the 
prostate  and  neck  ;  and  in  children,  by  reason  of  the  difficulty  in  keep- 
ing this  class  quiet  in  bed,  the  j^erineal  operation  is  preferred. 

In  females,  for  persistent  cystitis  vesico-vaginal  fistula  may  be  made, 
as  this  allows  the  adjustment  of  a  urinal,  and  permits  of  out-of-door  life. 
For  stone,  either  lithotrity  or  the  high  operation  should  be  performed. 

Perineal  UtJiotomy,  or  the  low  operation,  may  be  done  by  three 
methods — the  lateral,  bilateral,  and  median  operations.  A  combina- 
tion of  the  median  and  lateral  incisions  is  sometimes  performed,  and  is 
known  as  the  medio-lateral  procedure. 

Lateral  lithotomy  is  thus  performed :  Two  hours  before  the  operation 
the  rectum  should  be  emptied  by  a  free  enema  of  tepid  water,  and  the 
perineeum  cleanly  shaved.  The  patient  should  be  placed  upon  the  back, 
the  sacrum  resting  near  the  edge  of  the  table,  the  thighs  Hexed  toward 
the  abdomen,  slightly  abducted,  the  feet  brought  down  and  secured  to 
the  hands  and  wrists  by  several  turns  of  a  roller.  Each  leg  is  intrusted 
to  an  assistant,  while  a  third,  selected  for  his  special  fitness,  and  upon 

whom  the  duty  of  hold- 
ing the  guide  devolves, 
stands  beside  the  pa- 
tient's  abdomen,   facing 

Fig.  587.— Fergusson's  guide  for  lateral  lithotomy.  the  Operator. 

If  the  bladder  is  not 
fairly  distended  with 
urine,  a  Nelaton's  catheter  should  be  introduced,  and  about  a  pint  of 
fluid  injected.  A  Fergusson's  guide,  grooved  laterally  (Fig.  587),  is  next 
carried  into  the  bladder.  The  probabilities  are  that  the  stone  will  be  felt 
by  the  sound.  If  the  calculus  has  been  recognized  within  a  day  or  two, 
and  if  in  the  mean  time  the  urine  has  been  carefully  watched  and  no 


STONE   IN   THE   BLADDER— LITHOTOMY. 


659 


solid  substance  has  escaped  by  the  urethra,  no  prolonged  effort  should 
be  made  at  this  juncture  to  demonstrate  its  presence. 

The  proper  posi- 
tion for  the  guide  is 
shown  in  Fig.  588. 
The  shaft  is  held 
about  perpendicular 
to  the  surface  of  the 
table,  the  poiat  well 
into  the  bladder,  while 
the  convexity  of  the 
curve  rests  against 
the  perinseum.  The 
scrotum  is  now  lifted 
directly  upward,  and 
the  primary  incision 
is  made  with  the  sharp 
scalpel  (Fig.  53).     It 

commences  in  the  median  line  about  one  inch  and  a  half  directly  in 
front  of  the  anus,  and  is  carried  downward  and  outward  as  far  as  the 


Fig.  5S8. — Guide  in  position  in  lateral  lithotomy.     (After  Bryant.) 


Fio.  589.— e  l).  l-i 


in  lateral  lithotomy.     B  A.  Imaginary  line  between  the  tuberoaities  of 
the  ischia.     (After  Maclise.j 


posterior  margin  of  the  anus,  passing  half-way  between  the  inner  sur- 
face of  the  patient's  left  tuber  iscTiii  and  the  anal  margin  (Fig.  589). 


660  A  TEXT-BOOK  OlST  SURGERT, 

The  integument  and  fascige  having  been  divided,  the  operator  proceeds 
through  the  upper  half  of  the  vFOund  by  cutting  down  upon  the  guide, 
vfhich  may  be  readily  felt  with  the  finger.  When  this  is  nearly  reached, 
the  groove  in  this  instrument  will  be  made  out,  and,  by  pressing  the  nail 
of  the  left  index-finger  into  it,  the  point  of  the  knife  can  be  guided 
through  the  urethral  wall  into  the  groove,  making  an  opening  about  half 
an  inch  in  extent. 

With  the  finger-nail  kept  steadily  in  the  groove,  the  scalpel  is  laid 
aside,  and  the  long  probe-pointed  lithotomy-knife  (Fig.  54)  taken  up 
and  its  point  guided  into  the  groove  of  the  guide.  At  this  stage  of  the 
operation  the  sound  is  slightly  lifted  up,  so  that  the  pressure  which  has 
heretofore  been  made  upon  the  floor  of  the  urethra  will  be  transferred 
to  its  roof.  While  doing  this  the  probe-point  of  the  knife  should  be 
firmly  and  steadily  pressed  upward  against  the  instrument,  for,  unless 
this  precaution  is  observed,  it  may  slip  out  of  its  proper  place.  The 
operator  now  seizes  the  shaft  of  the  sound  with  the  left  hand  to  assure 
himself,  by  moving  this  instrument  slightly,  and  also  by  sliding  the 
knife  along  the  groove,  that  the  two  instruments  are  in  actual  contact, 
and  then,  turning  the  cutting  edge  of  the  knife  obliquely  toward  the 
patient's  left  side,  and  more  nearly  parallel  with  the  transverse  than 
with"  the  antero-iDosterior  diameter  of  the  j^atient's  body,  pushes  it  along 
the  grooved  guide  into  the  bladder.  In  executing  this  mancEuvre  it  is 
necessary  to  tilt  the  point  of  the  knife  upward  and  press  it  very  firmly 
into  the  groove  lest  it  slip  out  and  cause  confusion.  When  the  probe- 
point  arrives  at  the  end  of  the  groove  and  catches,  the  incision  through 
the  left  lobe  of  the  prostate  may  be  lengthened  by  pushing  the  sound 
with  the  knife  in  the  proper  direction.  As  the  incision  is  being  made,  a 
gush  of  urine  takes  place.  The  knife  is  now  withdrawn,  the  finger  car- 
ried into  the  bladder,  and  the  stone  located  before  the  sound  is  removed. 
The  size  of  the  calculus  should  be  determined,  and,  if  necessary,  the 
lower  portion  of  the  primary  incision  may  be  enlarged.  While  this  is 
being  accomplished,  it  is  advisable  to  carry  the  index-finger  into  the 
rectum  to  avoid  wounding  this  gut. 

The  forceps  (Fig.  590)  should  now  be  introduced  and  the  stone  re- 
moved. This  instrument  can  not  always  be  carried  in  through  the  wound 
if  the  finger  is  allowed  to  remain,  and  is  at  times  difiicult  of  introduc- 


FiG.  590. — Lithotomy-forceps. 


tion  without  a  guide.  To  prevent  delay,  the  conductor  (Fig.  591)  should 
be  passed  along  the  finger  into  the  bladder  and  allowed  to  remain  after 
the  finger  is  withdrawn.  If  the  blades  of  the  forceps  are  now  closed 
upon  the  flange  of  the  conductor,  the  instrument  can  be  made  to  slide 


STONE   IN   THE   BLADDER— LITHOTOMY. 


661 


accurately  along  the  guide  into  the  bladder,  after  which  the  conductor 
should  be  removed. 


Fig.  591. — Scoop  and  conductor. 

In  removing  a  stone  with  the  forceps  two  precautions  are  essential : 
1,  not  to  pick  up  the  wall  of  the  bladder  with  the  calculus  ;  and,  2,  not 
to  employ  force  enough  in  grasping  the  stone  to  crush  it. 

When  the  stone  is  grasped,  if  the  instrument  can  be  moved  freely 
within  the  bladder,  it  is  evident  that  this  organ  is  not  caught. 

With  small  calculi  the  extraction  is  easily  accomplished.  When  the 
stone  is  large,  a  certain  amount  of  force  is  justifiable  and  necessary  to 
stretch  the  wound  to  its  utmost :  but  this  force  should  never  be  used 
unless  the  operator  is  satisfied  that  the  stone  and  jaws  of  the  forceps 


Gouley's  lithoclast. 


can  be  brought  through  the  wound  without  serious  injury  to  the  blad- 
der and  prostate.  If  the  stone  can  not  be  extracted  whole,  it  should  be 
crushed  with  the  forceps  or  lithoclast  (Fig.  592),  and  removed  in  frag- 


FiG.  593. — Lithotomy-scoop. 

ments.     The  larger  pieces  may  be  caught  with  the  forceps,  the  smaller 
with  the  scoop  (Fig.  593).     A  stream  of  water  should  also  be  forcibly 


Fig.  594. — Van  Buren's  debris-syringe. 

thrown  in  through  the  wound,  in  order  to  bring  away  any  small  parti- 
cles which  may  have  escaped  notice  (Fig.  594).     Finally,  a  sound  should 


662 


A  TEXT-BOOK  ON  SURGERY. 


be  introduced  and  search  made  for  a  second  stone  or  any  fragments 

lodged  in  tlae  more  remote  portions  of  the  bladder. 

Among  the  accidents  which  may  complicate  perineal  lithotomy,  in 

addition  to  that  of  wounding  the  rectum,  which  has  been  mentioned,  is 

hsemorrhage  from  the  artery  of 
the  bulb  and  other  vessels  of 
the  perinseum.  The  ligature 
will  control  all  superficial  bleed- 
ing, and,  should  a  deep  vessel 
be  divided,  it  may  be  transfixed 
with  a  tenaculum  and  tied,  or 
the  hook  allowed  to  remain  in 
the  wound  for  a  day  or  two.  If 
the  oozing  is  free  and  general, 
an  umbrella-compress  (Fig.  595) 

should  be  made  by  tying  a  piece  of  oiled  silk  or  rubber  tissue  to  a 

canula  or  bougie.     This  is  carried  into  the  wound  and  compression  made 

by  packing  sponges  beneath  the  cloth  which  is  brought  in  contact  with 

the  bleeding  surface. 


Fig.  595. — Umbrella-compress. 


Fio.  596.— ^^,  Bulbous  portion  of  tlin  urctlira.      (\  Ki^lit  lateral  lobe  of  the  prostate,      i/,  The  line  of 
incision  in  lateral  lithotomy.     D,  Corpus  caveruosum.     jP,  Eectum.     j\',  "    •     ■  ■      ■         -    " 


deferens.     Z,  Artery  of  the  bulb.     (After  Maclise.) 


Vesicula  seminalis.     Q^  Va3 


The  after-treatment  of  lateral  lithotomy  is  simple.     The  wound  is  left 
open  and  unmolested.     The  urine  passes  through  this  for  a  few  days  or 


STONE  IN   THE  BLADDER— LITHOTOMY.  663 

weeks,  and  gradually  resumes  the  urethral  channel  as  the  Incision  closes 
by  granulation.  In  some  cases  the  iirine  passes  through  the  urethra  un- 
interruptedly.   The  patient  should  remain  in  bed  for  two  or  three  weeks. 

The  anatomical  relations  of  the  parts  involved  in  this  operation  are 
shown  in  Fig.  596. 

Bilateral  Lithotomy. — In  performing  this  operation  a  curved  incision 
is  made,  beginniag  half-way  between  the  tuberosity  of  the  ischium  and 
the  anus  on  one  side,  and  terminating  at  a  corresponding  point  on  the 
other.  The  incision  crosses  the  median  raphe  of  the  perinaeum  from  one 
half  to  three  quarters  of  an  inch  in  front  of  the  anus.  The  gaide  used 
in  this  operation  should  be  grooved  deeply  in  the  middle  of  its  convex 
surface.  As  soon  as  this  instrument  is  reached,  the  urethra  is  opened  in 
the  membranous  portion,  a,nd  the  finger-nail  carried  into  the  groove  on 
the  sound.  The  bisector — a  probe-pointed  two-edged  lithotome— is  in- 
troduced by  sliding  the  tip  of  the  insti'ument  along  the  nail  into  the 
groove.  The  operator  now  takes  hold  of  the  staff,  depresses  the  handle 
of  the  bisector,  and,  keeping  the  probe-point  in  the  groove,  pushes  the 
knife  into  the  bladder  directly  in  the  median  Kne.  In  this  operation 
the  prostate  is  divided  equally  on  both  sides  of  the  urethra. 

Median  Lithotomy. — The  position  of  the  patient  is  the  same  as  in 
the  two  preceding  operations.  The  best  staff  or  guide  is  that  of  Prof. 
Little  (Fig.  597),  which  has  a  deep,  wide  groove. 


Fig.  597. — Little's  litliotomy-staS. 


It  is  introduced  and  held  in  sucH  a  position  that  the  shaft  is  perpen- 
dicular to  the  plane  of  the  body,  the  tip  well  in  the  bladder,  with  the 
convexity  of  the  instrument  pressing  firmly  and  steadily  toward  the 
perinseum.  The  finger  is  now  carried  into  the  rectum  in  order  to  guard 
against  puncture  of  the  anterior  wall  of  this  organ.  The  knife  (Fig.  53) 
is  entered  just  about  a  half-inch  anterior  to  the  anus  in  the  median  line, 
the  edge  of  the  blade  directed  upward,  and  is  i)ushed  straight  inward 
until  the  point  strikes  into  the  concavity  of  the  groove  in  the  staff  at 
the  anterior  limit  of  the  prostate.  It  is  then  made  to  cut  forward  and 
upward  until  the  membranous  portion  is  divided,  and,  as  it  is  with- 
drawn, the  incision  in  the  perinseum  is  lengthened  in  all  about  one  and 
a  half  inch.  The  finger  is  now  introduced,  the  sound  withdrawn,  and 
the  wound,  prostatic  portion  of  the  urethra,  and  neck  of  the  bladder 
dilated  until  the  stone  can  be  felt  and  extracted  with  a  slender  forceps. 

Of  the  four  methods  of  cutting  for  stone  just  described,  the  lateral 
and  supra-pubic  operations  are  preferable.     The  bilateral  procedure  is 


664  A  TEXT-BOOK  ON  SURGERY. 

at  this  time  rarely  performed.  In  the  extraction  of  an  ordinary  stone 
the  incision  through  one  lobe  of  the  prostate  will  be  sufficient.  When 
the  calculus  is  so  large  that  a  wider  incision  is  required,  the  right  lobe 
may  be  readily  incised  through  the  lateral  wound.  The  median  opera- 
tion is  objectionable  on  account  of  the  danger  of  injuring  the  prostate 
and  neck  of  the  bladder,  in  the  necessary  dilatation,  or  in  efforts  at  extrac- 
tion. It  is  only  applicable  to  the  removal  of  the  very  smallest  calculi  in 
children  or  youths  in  whom  a  lithotrite  and  evacuating-catheter  can  not 
be  introduced.  Even  in  this  class  of  cases  the  lateral  operation  should 
be  given  the  preference.  The  siipra-pubic  incision  has,  within  late  years,  ■ 
become  a  more  popular  operation.  It  is  applicable  (1)  when  the  stone 
is  of  large  size — from  one  and  a  half  to  two  inches  and  over  in  diame- 
ter— the  removal  of  which  by  a  perineal  incision  would  involve  an  ex- 
tensive incision  or  laceration  of  the  neck  of  the  bladder  and  prostate ; 
(2)  where  the  calculus  is  lodged  high  up  behind  the  pubes,  either  with 
or  without  enlargement  of  the  prostate  and  concentric  hypertrophy  of 
the  neck  and  base  of  the  bladder,  since  in  these  conditions  a  stone  can 
be  reached  through  the  perinseum  only  at  great  depth  and  with  much 
difficulty.  On  the  other  hand,  it  is  readily  found  through  a  supra-pubic 
incision.  The  high  operation  is  indicated  in  deformity  of  the  pelvis, 
with  narrowing  of  the  inferior  strait.  The  difficulty  and  danger  of  this 
procedure  are  increased  in  corpulent  and  fat  persons. 

Stone  in  the  Bladder  of  Females. — Vesical  calculi  are  not  met  witli 
in  females  as  frequently  as  in  males.  Many  conditions  which  con- 
duce to  the  lodgment  or  formation  of  stone  in  the  male  bladder,  and 
are  common  in  this  sex,  are  either  impossible  to,  or  rarely  occur  in, 
females.  Among  these  causes  may  be  mentioned  hypertrophy  of  the 
prostate  with  obstruction,  and  chronic  cystitis  and  organic  stricture  of 
the  urethra. 

Another  explanation  of  the  comparative  infrequency  of  stone  in  fe- 
males is  the  short  and  dilatable  urethra,  allowing  the  escape  of  many 
small  concretions  which  in  men  would  lodge  in  the  cul-de-sac  behind  the 
prostate.  The  symptoms  do  not  differ  from  those  given  in  stone  in  the 
bladders  of  males.  The  diagnosis  rests  upon  exploration  with  a  searcher, 
combined  with  digital  exploration  ^er  vaginaTn,  and  direct  pressure  over 
the  pubes. 

Treatment. — The  large  majority  of  calculi  found  in  the  bladders  of 
females  may  be  readily  removed  by  lithotrity.  The  short  and  distensi- 
ble urethra  permits  of  the  introduction  of  the  largest  evacuating-cathe- 
ter, and  greatly  facilitates  the  operation.  The  crushing  operation  is 
preferable  in  small  stones  to  the  older  method  of  dilatation  or  divulsion 
of  the  urethra  and  extraction  in  mass  by  forceps.  A  miich  larger  stone 
may  be  crushed  and  removed  from  the  female  bladder  than  can  possibly 
be  done  from  the  male  organ  within  the  limit  of  safety  at  a  single  opera- 
tion. When  lithotomy  becomes  necessary,  the  operator  must  choose 
between  the  vesico-vaginal  and  supra-pubic  incision.  In  the  former  a 
second  operation  for  vesico-vaginal  fistula  is  essential.  In  case  the  pa- 
tient is  very  fat,  the  low  operation  will  be  advisable.     In  ordinary  sub- 


FOREIGN  BODIES  IN   THE   BLADDER. 


665 


jects  the  supra-pubic  operation,  carefully  and  properly  done,  offers  the 
best  prospect  of  speedy  relief. 

Foreign  Bodies. — Foreign  substances  in  the  bladder  are  usually  intro- 
duced through  the  urethra.  Less  frequently  they  pass  through  the  walls 
of  this  organ,  as  in  gnnshot-wounds,  etc.  In  exceptional  instances  for- 
eign matter  finds  its  way  into  this  organ  through  a  fecal  or  vaginal  iistula. 
In  several  cases  of  this  character  worms  have  escaped  from  the  intestines 
and  found  an  exit  through  the  urethra. 

The  symptoms  are  usually  those  of  stone  in  the  bladder,  with  cystitis 
in  a  varying  degree.  The  diagnosis  may  be  evident  from  the  history  of 
an  accidental  or  intentional  introduction  of  the  foreign  substance.  The 
matter  can  usually  be  recognized  by  the  searcher.  If  a  few  weeks  have 
elapsed,  the  substance  will  probably  be  coated  with  a  deposit  of  urinary 
salts,  and  wiU  impart  to  the  sound  the  grating  or  click  peculiar  to  stone. 

The  treatment  consists  in  removal  of  the  offending  substance  as  soon 
as  possible.  If  it  is  small,  round,  and  smooth,  it  may  be  extracted 
through  the  urethra,  with  the  lithotrite.  For  this  purjiose  the  smallest 
instrument  should  be  employed.  If  it  is  too  large  to  be  brought  out  in 
mass,  it  may  be  chopped  up  or  crushed,  and  then  extracted  piecemeal, 
in  the  Jaws  of  the  lithotrite,  or  washed  out  thi'ough  the  evacuator. 
Fig.  598  represents  an  English  gum  catheter  which  was  removed  in  this 


mm 


*iw9 


Fic.  59S. — Gum  citheter  tli.-l, 


tLe  lithotrite.     (The  niitlior's  case.) 


manner.  The  two  larger  pieces  were  grasped  by  the  end  and  drawn 
out ;  the  remainder  was  caught  in  the  lithotrite,  and  brought  out  one 
piece  at  a  time. 

"When  the  substance  is  so  large  or  of  such  a  shape  that  it  can  not  with 
safety  be  brought  through  the  urethra,  cystotomy  is  imperative.  In 
determining  upon  the  method  of  opening  into  the  bladder,  the  same  rules 
will  ai^ply  as  given  for  lithotomy.  . 

T7ie  Prostate  Body. — Disease  of  the  prostate  is  almost  always  a  con- 
dition of  adult  life.  This  organ  is  rudimentary  in  childhood,  and  while, 
from  dii'ect  injury,  as  in  catheterization,  lithotomy,  or  any  form  of  vio- 
lence, or  by  the  extension  of  any  of  the  rarer  forms  of  disease  which 
affect  the  bladder  or  urethra  of  children,  this  body  may  be  involved,  it 
only  assumes  its  true  importance  after  it  has  taken  on  its  functional 
activity. 

Prostatitis. — Inflammation  of  the  prostate  may  be  partial  or  complete, 
as  well  as  acute  and  chronic.     It  may  affect  the  epithelial  and  glandular, 


666 


A  TEXT-BOOK   ON  SURGERY. 


or  muscular  and  connective-tissue  structure  of  tMs  complex  organ.  Pros- 
tatitis rarely  originates  in  the  substance  of  this  body,  being  usually 
involved  by  extension  of  an  inflammation  from  the  bladder,  urethra,  or 
other  organs  and  tissues  in  its  immediate  neighborhood.  Urethritis, 
cystitis,  epidydimitis,  and  proctitis  are  among  the  more  common  causes 
of  prostatitis.  To  these  may  be  added  excessive  venereal  excitement,  all 
forms  of  traumatism,  whether  by  violence  applied  to  the  rectal  or  perineal 
regions,  or  by  instruments  in  the  urethra,  and  the  presence  of  calcareous 
or  amylaceous  concretions. 

The  symptoms  are  usually  well  marked.  Pain  in  the  acute  form  of 
inflammation  is  usually  intense  and  burning  in  character.  There  is  a 
sense  of  fullness  and  throbbing  in  the  organ.  With  the  finger  in  the 
rectum  its  enlargement  may  be  appreciated,  together  with  abnormal  heat 
and  throbbing  of  the  arteries  along  its  base.  Pain  is  increased  by  direct 
pressure  in  the  perinseum  or  rectum,  and  also  in  the  act  of  urination. 
Fever  is  pi'esent  in  proportion  to  the  severity  of  the  local  process.  Sup- 
puration and  the  formation  of  abscess  are  usually  indicated  by  exacerba- 
tions of  temperature  and  by  interference  with  micturition. 

The  first  indication  in  the  treatment  of  this  painful  affection  is  rest  in 
the  recumbent  posture.  The  bowels  should  be  kept  open.  The  ice-bag 
to  the  perinpeum  will  be  found  agreeable  and  of  value.  If  retention  of 
urine  occurs,  it  should  be  relieved  by  the  use  of  the  smaller  soft  catheter. 
Supra-pubic  aspiration  may  be  demanded  in  severe  cases.  Scarification 
of  the  perinseum  and  the  application  of  cups  are  highly  recommended  as 
local  measures.    If  abscess  exists,  it  should  be  evacuated  by  the  aspirator. 

Rupture  may  occur  into  the 
urethra,  or  the  abscess  may 
find  an  opening  through  the 
perinseum  or  rectum. 

Hypertrophy. — Chronic 
progressive  enlargement  of 
the  prostate  occurs  in  about 
one  third  of  all  males  who 
live  through  the  period 
from  fifty  to  seventy-five 
years  of  age.  The  increase 
in  volume  is  not  a  true  hy- 
perplasia, for  the  glandular 
functions,  as  well  as  the 
muscular  power  of  the  or- 
gan, decrease  with  the  hy- 
pertrophy. In  some  por- 
tions of  the  mass  the  mus- 
cular tissue  is  increased, 
but  the  bulk  of  the  enlarge- 

FiG.  599. — Longitudinal  section  of  hypertrophied  prostate,  in  ment  is  due  tO  the  DreseUCe 
a  patient    seventy-four    years   of   age  ;    showing   a  false  -^  . 

passage  tunneled  by  a  catheter.     5,  Line  of  transverse  see-  of  Uewly  formed  Connective 

tion  sliown  in  Fig.  600.    a,  Duct  of  vesicula  seminalis.  (Af-  ,.  „,       .     ,  ,.        .     . 

ter  Sooin.)  tissue.    The  induratiou  IS  lu 


HYPERTROPHY  OF   THE  PROSTATE. 


667 


Fig.  600. — Transverse  section  through  the 
center  of  the  prostate  of  a  patient 
seventy-four  years  old.  Hypertrophy 
of  fouiteen  years'  duration,  a.  Ure- 
thra. 6,  Caput  gallinaguinis.  (After 
Socin.) 


proportion  to  the  excess  of  the  new  tissue  over  the  normal  muscular  and 
glandular  elements.  In  some  instances,  though  rarely,  the  glandular 
elements  are  increased ;  but  this  is,  in  great  probability,  only  observed  in 
the  earlier  stages  of  hypertrophy,  before 
the  connective-tissue  elements  are  in  suf- 
iicient  quantity  to  cause  atrophy  of  the 
glandular  apparatus.  The  enlargement 
may  be  local  or  general.  In  general  hy- 
pertrophy, while  the  increase  in  size  is  in 
all  directions,  it  is  more  marked  in  the 
posterior  portions,  where  it  encroaches 
upon  the  neck  of  the  bladder.  Not  in- 
frequently one  lateral  lobe  is  greatly  en- 
larged, or  the  hypertrophy  may  be  cen- 
tral, resulting  in  the  development  of  a 
middle  or  third  lobe,  which,  by  progres- 
sive enlargement,  not  only  changes  the 
axis  of  the  normal  urethra,  but  occludes, 
in  a  variable  degree,  the  outlet  of  the 

bladder.  This  last  condition  is  well  shown  in  Fig.  599,  and  that  of 
general  hypertrophy  of  the  muscular,  fibrous,  and  glandular  tissxies, 
with  narrowing  of  the  urethra,  in  Fig  600. 

Symptoms. — The  increase  in  size  is  usually  so  gradual  that  the  condi- 
tion of  hypertrophy  does  not  attract  the  attention  of  the  patient  until 
interference  with  the  flow  of  urine  occurs.  As  a  result  of  retention  the 
bladder  is  distended,  the  contractility  of  its  muscular  waUs  is  diminished, 
and  chronic  cystitis  inevitably  ensues.  The  changes  which  take  place  in 
this  organ — thickening  of  the  waUs,  occasional  sacculation,  the  formation 
of  calculi,  dilatation  of  the  ureters,  etc. — have  been  given.  In  severe 
cases  the  functions  of  the  rectum  may  be  interfered  with. 

The  diagnosis  maybe  determined 
by  the  presence  of  the  symptoms 
just  given,  by  digital  exploration  by 
the  rectum,  and  the  introduction  of 
a  sound  or  bougie  by  the  urethra. 

The  treatment  is  chiefly  pallia- 
tive.    When  recognized  early  in  its 
history,   every  source  of    irritation 
should  be  removed  fi'om  this  organ. 
The  bowels  should  be  kept  open, 
the  irritability  of  the  urine  dimin- 
ished by  the  administration  of  alka- 
line diluents,  and  all  venereal  ex- 
citement  prohibited.     In   those   af- 
fected   with    gout    or    rheumatism, 
^'"tr-bTaliert^tp^ifa'iS^uLtat^^     judicious  diet  and  medicatiou  may 
normal  condition  of  this  body.   The  bristle     arrest,  or  at  least  retard,  the  prog- 
is  passed  from  the  ejaeulatory  duct  into  the  «      ,         -••  •       ^i 

uretiira.   (After  Soein.)  ress  of  the  disease  in  tne  prostate. 


668 


A  TEXT-BOOK  ON  SURGERY. 


When  symptoms  of  obstruction  to  the  escape  of  urine  supervene,  oper- 
ative interference  is  frequently  called  for.  If  the  hypertrophy  is  gen- 
eral, and  the  caliber  of  the  urethra  is  encroached  upon,  dilatation  by 
means  of  the  olive-pointed  French  bougies  or  the  conical  steel  sounds 


■,-\-^\^' 


<■, 


Fig.  602. — Hypertrophy  of  the  prostate,  showing  the  asymmetrical  development  of  the  middle  or  thiid 
lobe,     a  a,  Openings  of  ui'etera.     (After  Socin.) 

may  be  required.  When  the  enlargement  is  chiefly  in  the  posterior 
portions  of  the  organ,  dilatation  is  not  indicated.  In  order  to  prevent 
cystitis,  it  is  important  that  every  effort  should  be  made  to  thoroughly 
empty  the  bladder  at  each  act  of  urination. 

The  relation  of  the  urethra  to  the  base  of  the  bladder,  in  the  normal 

condition  of  the  prostate,  is 
well  shown  in  Fig.  601.  The 
impediment  to  the  complete 
evacuation  of  the  bladder  in 
enlargement  of  the  posterior 
and  middle  portions  of  this 
body  may  be  more  readily 
understood  by  referring  to 
Figs.  602  and  603. 

If  the  sitting  or  standing 
posture  is  maintained,  it  is 
evident  that  a  certain  quan- 
tity of  urine  will  remain  in 
the  cul-de-sac,  behind  the 
prostate,  even  if  the  ball- 
valve  formed  by  the  hyper- 
trophied  middle  lobe  is  held 
back  by  the  catheter.  In 
many  cases  this  difficulty 
may  be  overcome  and  benefit  gained  by  evacuating  the  bladder,  with  or 
without  the  catheter,  in  the  knee-shoulder  position.    The  introduction 


Fig,  603. — Antero-posterior  section  of  the  same  specimen. 


HYPERTROPHY   OF   THE  PROSTATE. 


669 


of  the  catheter  in  prostatic  hypertrophy  is  such  an  important  feature  in 
the  treatment  of  this  disease,  and  at  times  is  surrounded  -nith  such  diffi- 
culties, that  it  becomes  important  in  each  case  to  study  the  condition  of 
the  neck  of  the  bladder  and  urethra,  to  determine,  with  as  much  accu- 
racy as  possible,  the  deviation  of  this  channel  from  the  nonnal. 

it.  ^^  w.'*^  / 


^ 


Fig.  604.— The  normal  urethra  of  a  male  adult.     From  a  frozen  section.     Keduced  from  life  size. 
(After  Braune.) 

The  normal  curve  of  the  urethra  is  shown  in  Figs.  604,  605.     AYhen 
hypertrophy  of  the  prostate  occurs,  the  distortion  is  practically  an  elon- 
gation   and    exaggeration   of    the 
natural  curve  from  the  tiiangular 
ligament  back  to  the  opening  into 
the  bladder  (Figs.  606,  607). 

In  the  exploration  an  olive- 
pointed  black  French  catheter,  in 
size  aboiit  No.  14  (U.  S.  scale),  will 
be  found  to  be  a  safe  and  satisfac- 
tory instrument.  If  warmed  and 
oiled,  it  will  usually  pass  to  the 
neck  of  the  bladder  without  resist- 
ance, and,  in.  a  majority  of  in- 
stances, the  obstruction  may  be 
overcome  by  pushing  steadily  upon 
the  catheter.  ]S"o  hann  can  arise 
from  this  procedure.  If,  however, 
the  bladder  is  not  entered,  the  in- 
strument should  be  withdrawn,  armed  with  the  wii-e  stylet,  bent  to 
suit  the  curve  of  the  deep  urethra,  and  again  introduced.  A  careful 
degree  of  force  inay  now  be  employed  to  overcome  the  obstruction. 


Fig.  605. — The  sound  passing 
curve  of  the  urethra.  (A 
Keyes.) 


around  the  norma! 
;er  Van  Buren  and 


670 


A  TEXT-BOOK   ON    SURGERY. 


but  undue  violence  must  be  avoided.     The  distal  end  of  the  catheter 
and  stylet  should  be  well  depressed  in  the  effort  to  pass  by  the  obstruc- 


Fia.  606. — The  change  in  the  direction  of  the  urethra  caused  by  hypertrophy  of  the  prostate.     (After  Socin.) 

tion.  If  the  manoeuvre  is  successful,  the  stylet  is  withdrawn,  leaving 
the  catheter  in  position  untU  the  bladder  is  emptied.  If  the  intro- 
duction can  not  be  effected,  suxjra-pubic  aspiration  may  be  done,  and 

the  patient  should  be  put 
to  bed  and  narcotized  with 
morphia.  Under  the  quiet- 
ing influence  of  this  rem- 
edy spasm  of  the  muscu- 
lar fibers  of  the  prostate 
and  vesical  neck  is  allayed, 
frequently  resiilting  in  tem- 
porary relief  from  reten- 
tion. Its  value  can  scarce- 
ly be  overestimated  in  the 
management  of  obstinate 
cases  of  retention  and  cys- 

FiG._  607. —Showing  the  increase  in  the  curve  of  the  urethra       titis  CaUSed  by  prostatic  hy- 
in  prostatic   hypertrophy,  and  the  necessity  of  a  longer  ,  ^       •, 

curve  in  the  catheter.     (After  Van  Buren  and  Keyes.)  pertropny. 


HYPERTROPHY   OF   THE   PROSTATE. 


671 


The  propriety  of  operative  interference,  beyond  catheterization  or 
puncture  of  the  bladder,  may  be  entertained  in  a  certain  proportion  of 
cases.  It  is  especially  indicated 
when  intense  urethritis  is  caused  by 
the  necessary  and  repeated  cathe- 
terization. Under  such  conditions, 
cystotomy  may  be  done,  or  an  effort 
may  be  made  to  destroy  the  hyper- 
trophse  by  Mercier's  instrument. 

Supra  -  pubic  cystotomy  offers 
the  most  accessible  route  to  this 
cause  of  obstruction,  and  is  not  at- 
tended with  great  danger.  In  one 
of  the  author's  cases,  the  hyi^ertro- 
phy  was  identical  with  that  shown 
in  Fig.  608,  and  was  i-eadily  re- 
moved. The  patient  was  sixty-nine 
years   of    age,   and    for    seventeen 

years  had  used  the  catheter.     After  the  operation,  the  urine  could  be 
passed  per  urethram. 

Mercier's  excisor  is  shown  in  Fig.  609.  In  construction  it  resembles 
the  lithotrite,  with  the  exception  that  the  beaks  are  shorter  and  are  not 
serrated.  The  mechanism  of  the  instrument  is  practically  the  same. 
The  operation  is  performed  as  follows :  The  kiotome  is  closed,  oiled,  and 


Fio.  608. — A  ridge  of  hypertrophied  prostate  seen 
from  within  the  bladder.     (After  Sooin.) 


Fio.  609. — Mercier's  instrument  for  the  re- 
moval of  portions  of  the  hyperti'ophied 
prostate.  The  cutting  portion  (^)  is 
life  size.    (After  Socin.) 


carried  into  the  bladder,  which  should  be  fairly  distended.  The  opera- 
tor should  move  the  instrument  about  freely,  and  turn  it  on  its  axis,  in 
order  to  be  assured  that  it  is  well  within  the  organ.  It  is  then  with- 
drawn, with  the  beak  pointing  upward,  until  it  is  felt  to  be  arrested  at 
the  opening  into  the  urethra.  While  in  this  position  the  blades  are  sepa- 
rated a  half-inch,  the  instrument  forced  to  one  side  (the  patient's  right), 
then  steadily  turned  to  the  left  and  closed.  If  the  obstruction  is  seized 
by  this  manoeuvre  the  screw-movement  is  adjusted,  and  the  part  grasped 
is  cut  off  and  withdrawn  with  the  closed  instrument.  Mercier's  pro- 
cedure, although  not  frequently  performed,  has  met  with  a  success  which 
justifies  its  repetition.  In  well-selected  cases  it  can  not  but  be  useful, 
and  when  the  urethra  and  bladder  are  carefully  accustomed  to  the  use 
of  a  catheter,  it  gives  little  pain  or  inconvenience.  The  employment  of 
an  anaesthetic  is  not  indicated,  the  sensation  of  the  patient  being  of 
value  in  aiding  the  surgeon  to  determine  when  the  tissue  is  grasped. 


672  A  TEXT-BOOK   ON  SURGEKY. 

In  hopeless  cases  of  cystitis  resulting  from  obstruction  of  the  urethra, 
from  xjrostatic  hypertrophy,  cystotomy,  with  the  establishment  of  a  per- 
manent urinary  fistula,  may  become  necessary.  The  various  methods  of 
j)erforming  this  operation  have  akeady  been  described. 

ProstatorrJiosa. — Chronic  prostatitis,  or  catarrh  of  the  prostate,  in  a 
majority  of  cases  follows  an  acute  inflammation  of  this  organ.  Its  chief 
cause  is,  therefore,  an  extension  of  a  cystitis  or  urethritis  to  the  epi- 
thelial lining  of  the  glandular  portions  of  this  body.  In  a  certain  pro- 
portion of  cases  it  originates  as  a  subacute  inflammatory  process  located 
in  the  glandular  substance.  It  is  in  this  form  most  frequently  seen  in 
weak,  scrofulous,  or  tubercular  adults  about  the  period  of  puberty. 
Prostatorrhcea  is  a  symptom  of  general  hypertrophy  of  this  organ  in 
the  earlier  stages  of  enlargement,  gradually  diminishing  as  the  connect- 
ive-tissue hyperplasia  encroaches  upon  and  destroys  by  compression 
the  glandular  apparatus. 

The  leading  symptom  of  this  disease  is  the  discharge  of  a  small 
quantity  of  bluish- white  fluid  from  the  meatus.  It  is  noticed  particu- 
larly by  the  patient  before  the  first  micturition  in  the  morning,  haviog 
accumulated  during  the  night.  A  drop  or  two  may  be  sqiieezed  from 
the  urethra  by  pressure  along  the  under  surface  of  the  penis  from  the 
perinseum  forward.  It  is  carried  out  ■with  the  first  flow  of  urine,  and, 
if  not  observed  previously,  usually  escapes  notice.  In  the  severer  type 
of  cases  the  prostatic  fluid  may  be  seen  immediately  after  urinating 
or  during  the  intervals  of  micturition,  as  a  bluish  mucus,  moisten- 
ing the  meatus  and  prepuce,  and  slightly  tenacious  and  stringy  when 
wiped  ofl^.  This  fluid  is  also  frequently  observed  when  the  contents 
of  the  rectum  are  discharged,  especially  if  the  fseces  are  hard  and  fully 
formed.  Prostatorrhcea  occurs  in  excessive  or  prolonged  venereal  ex- 
citement. 

The  diagnosis  of  this  afi'ection  depends  upon  the  exclusion  of  sper- 
matorrhoea and  urethritis.  The  symptoms  of  spermatorrhoea  are  in  gen- 
eral so  similar  to  those  of  prostatorrhcea,  that  a  positive  differentiation 
can  only  be  made  by  microscopical  examination.  The  fluid  which  es- 
capes may  be  examined  alone,  or  the  first  ounce  or  two  of  urine  passed 
after  a  comparatively  long  interval  in  urinating  may  be  caught  in  a  sepa- 
rate vessel,  allowed  to  settle,  and  a  drop  of  the  sediment  placed  upon 
the  sUde.  The  presence  of  spermatozoa  will  confirm  the  diagnosis  of 
spermatorrhoea.  The  urine  first  passed  after  a.  discharge  of  semen  should 
not  be  examined,  since  under  such  conditions  these  elements  are  found 
in  perfectly  normal  subjects.  In  differentiating  between  prostatorrhcea 
and  gleet,  the  exploration  of  the  urethra  will  be  necessary.  The  absence 
of  a  stricture  or  of  marked  tenderness  in  the  canal  in  front  of  the  pros- 
tatic portion  will  exclude  urethritis,  with  the  exception  of  a  rare  form 
of  chronic  follicular  urethritis,  which,  as  will  be  seen  further  on,  may 
or  may  not  be  preceded  by  a  gonorrhcea  or  stricture.  In  follicular  ure- 
thritis, tenderness  is  not  marked.  If  a  large-sized  bulbous  wire  bougie 
is  carried  back  to  the  membranous  portion  of  the  urethra,  and  is  then 
withdrawn  whUe  the  urethra  is  held  in  close  contact  with  it,  the  yellow- 


PROSTATORRHCEA. 


673 


ish-wliite  flakes  or  plugs  of  clieesy  material  will  be  squeezed  out  of  the 
follicles  and  be  seen  adhering  to  the  bulbs. 

Treatment. — The  correction  of  any  diathesis  which  predisposes  to  a 
catarrhal  condition  of  the  mucous  membranes  is  an  important  step  in 
the  general  treatment  of  prostatorrhcea. 

Among  the  local  measures,  distention  of  the  prostatic  urethra  by  the 
introduction  of  steel  sounds,  is  advisable.  The  larger  sizes  should  be 
employed,  and  if  the  meatus  is  so  narrow  that  it  will  not  admit  Xo.  20  or 
21  (U.  S.\  it  should  be  incised  up  to  this  point  as  a  preparatory  measure. 
"When  stricture  exists,  internal  urethrotomy  should  be  performed.  The 
dilatation  may  be  commenced  with  Xo.  17  and  increased  to  Xo.  21  at  a 
single  operation ;  or,  if  the  procedure  is  attended  with  pain  of  a  severe 
nature,  the  larger  numbers  may  be  used  at  the  third  or  fourth  introduc- 
tion. The  point  of  the  sound  should  not  be  carried  farther  than  the 
neck  of  the  bladder,  which  is  between  seven  and  eight  inches  from  the 
meatus.  The  operation  should  be  repeated  from  two  to  three  times  a 
week — not  often  enough  to  cause  a  general  urethritis. 


Van  Buren's  cupped  sound. 


Local  medication  is  at  times  of  great  value.  The  cupped  sound  (Fig. 
610),  which  consists  of  an  ordinary  instrument  with  from  six  to  eight 
spoon-shaped  depressions  just  beyond  the  curve,  is  a  valuable  instrument. 
In  employing  it,  a  stiff  salve  must  be  made  by  mixing  the  medicine  re- 
quired with  simple  cerate.  Lard  melts  too  rapidly,  and  is  therefore  objec- 
tionable. The  cups  are  filled  just  to  the  level  of  the  surface,  the  instru- 
ment thoroughly  lubricated  and  rapidly  carried  down  to  the  prostate, 
where  it  is  allowed  to  remain  for  several  minutes,  until  the  heat  of  the 
part  melts  the  salve.  Tannic  acid  (grs.  x-xx  or  xsx  to  |  j)  or  acetate  of 
lead  or  nitrate  of  silver,  in  proper  proportions,  may  be  thus  employed. 


Fig.  611. — Garreau's  prostatic  syringe.     (After  Socin.) 


Another  method  is  the  introduction  of  silver  nitrate  or  other  escharot- 
ics  or  astriugents  by  means  of  the  canulated  sound  (Fig.  611),  which 
consists  of  a  metal  tube  shaped  like  a  catheter,  through  which  a  stylet- 
piston  plays.  A  sufficient  quantity  of  the  ointment  is  placed  in  the  cyl- 
inder near  its  open  end,  and  the  piston  introduced.  TVken  the  tip  of  the 
instrument  arrives  at  the  prostate,  it  is  emptied  by  forcing  the  piston 
down,  at  the  same  time  slightly  withdi-awing  the  catheter  in  order  to 
distribute  the  contents  over  the  entire  prostatic  surface. 

43 


674  A  TEXT-BOOK  ON  SURGERY. 

It  is  readily  understood  that,  locally  applied,  no  agent  is  carried  to 
the  deeper  portions  of  the  glandular  substance,  but  the  inflammation 
precipitated  in  the  more  superficial  glands  and  the  ducts  of  those  more 
deeply  situated,  may  readily  travel  along  the  epithelial  liaing  until  the 
entire  gland- tissue  is  involved. 

Beyond  the  danger  of  a  temporary  elevation  of  temperature  vphich 
may  occur  in  patients  subjected  to  urethral  exploration,  the  additional 
dangers  of  cystitis  and  epididymitis  should  not  be  disregarded.  The 
use  of  the  double-current  closed  catheter,  with,  hot  or  cold  water,  is 
one  of  the  most  satisfactory  and  safe  methods  of  treating  this  disease. 
Its  employment  wiU  be  described  in  the  treatment  of  chronic  follicular 
urethritis.  The  j)rognosis  in  prostatorrhoea  should  be  guarded,  for  many 
cases  obstinately  resist  the  most  cai'eful  and  energetic  measures  of  treat- 
ment. 

SpermatorrTicea. — This  term  is  used  to  designate  the  escape  of  semen 
from  the  ejacnlatory  ducts  without  an  orgasm.  This  fluid  may  find  its 
way  into  the  bladder,  but  usually  escapes  by  the  meatus.  The  symp- 
toms of  this  disease  do  not  difi'er  materially  from  those  given  in  pros- 
tatorrhoea. The  diagnosis  can  only  be  made  certain  by  the  recognition 
of  the  spermatozoa  with  the  aid  of  the  microscope.  It  occurs  at  times  in 
conditions  of  great  physical  prostration,  as  a  result  of  excessive  and  un- 
natural venereal  indulgence,  and  from  interference  with  the  function  of 
the  muscular  elements  of  the  prostate. 

The  treatment  is  general  and  local.  Measures  looking  to  the  im- 
provement of  the  moral  and  physical  condition  of  the  patient  should  be 
adopted.  The  local  treatment  is  the  same  as  that  given  for  prostator- 
rhoea. 

As-permatisTn. — The  spermatozoa  are  wanting  in  adults  whose  testi- 
cles have  been  removed  or  destroyed  by  disease,  in  patients  in  whom 
both  organs  have  failed  to  descend  and  have  undergone  atrophy  ;  in  all 
cases  of  complete  obstruction  of  the  wisa  defer entia  or  ejacnlatory  ducts, 
and  in  certain  cases  of  senile  atrophy  of  these  organs.  These  conditions 
are  rarely  amenable  to  surgical  treatment. 

Tuberculosis  of  the  Prostate. —  Tubercular  disease  of  this  organ, 
though  rarely  observed,  may  be  primary,  or  more  frequently  is  second- 
ary, to  tubercular  deposit  in  other  viscera,  as  the  testis,  epididymis, 
lungs,  etc.  It  is  more  apt  to  occur  in  the  young  and  iniddle-aged  than 
in  the  old.  The  diagnosis  can  not,  as  a  riile,  be  easily  made.  In  some 
cases  there  are  no  symptoms  of  tuberculosis.  If  with  a  subacute  or 
chronic  lesion  of  this  organ  there  is  a  history  of  phthisis,  the  deposit  of 
tubercular  matter  may  be  suspected.  When  the  febrile  movement,  hec- 
tic, profuse  sweats  and  emaciation  of  this  disease  are  present,  a  correct 
diagnosis  is  readily  made.  The  enlargement  and  nodular  character  of 
the  prostate  may  be  made  out  by  digital  exploration  by  the  rectum.  The 
treatment  is  altogether  palliative. 

Carcinoma. — Cancer  of  the  prostate  is  also  rare.  It  is  more  apt  to 
occur  primarily  than  by  metastasis.  Primary  cancer  of  this  organ  is 
more  frequently  seen  in  young  adults  than  in  tlie  old.     In  the  middle- 


PROSTATIC   CONCRETIONS. 


■675 


aged  and  old  it  is  more  likely,  to  occur  by  invasion  from  a  neighboring 
organ,  as  tlie  rectum. 

In  the  earlier  stages  the  symptoms  of  this  disease  do  not  differ  mate- 
rially from  those  of  simple  hypertrophy.  As  simple  hypertrophy  is  rare 
in  the  young  and  middle-aged,  the  presence  of  a  tumor  of  this  organ  at 
this  time  of  life  should  be  regarded  with  a  suspicion  of  malignancy. 
The  absence  of  the  symptoms  of  abscess  is  in  some  degree  a  confirma- 
tion of  this  suspicion.  If  the  tumor  develops  rapidly,  carcinoma  or 
sarcoma  may  be  diagnosticated,  for,  although  the  disease  may  continue 
for  one  or  two  years,  or  even  longer,  the  invaded  organ  soon  assumes  a 
size  not  met  with  in  non-malignant  hypertrophy.  Haemorrhage  of  a  pro- 
fuse character  is  apt  to  follow  the  introduction  of  a  sound  or  catheter 
when  carcinoma  or  sarcoma  is  present. 

Sarcoma  is  also  rare  in  this  organ  (Fig.  612).  It  is  more  apt  to  oc- 
cur in  the  young  than  in  the  middle-aged  and  old.  The  symptoms  differ 
in  no  essential  feature  from  those  present  in  cancer.  The  prognosis  of 
both  diseases  is  grave,  and  the  treatment  palliative. 

Prostatic  Concretions.  — Concre- 
tions in  this  organ  are  of  two  kinds — 
the  corpora  amylacea  and  calculi. 


Fio.  612. — Sarcoma  of  the  prostate  and  neck  of 
the  bladder,  with  obstruction.  The  catheter 
has  tunneled  the  neoplasm.     (After  Socin.) 


Fig.  613. — Calculi  in  the  prostatic  follicles. 
(Alter  Socin.) 


The  former  are  small  bodies  which  frequently  exist  in  the  follicles  of 
the  prostate.  Their  mode  of  origin  is  unknown.  They  give  the  well- 
known  amyloid  reaction  with  iodine.  Stone  in  the  prostate  may  origi- 
nate in  the  deposit  of  inorganic  elements  from  the  blood  and  fluids  of 
this  organ,  either  in  the  follicles  originally  (Fig.  613)  or  as  accretions 
upon  the  amyloid  bodies  just  described. 

The  symptoms  of  prostatic  concretions  are  chiefly  those  due  to  the 
inflammation  or  enlargement  which  they  produce.  Corpora  amylacea 
not  infrequently  exist  in  the  prostate,  causing  little  or  no  discomfort. 
When  of  large  size,  especially  when  they  grow  by  reason  of  a  deposit 
of  inorganic  substances,  they  cause  inflammation  of  the  follicles  and 
destruction  of  the  glandular  epithelia.  A  positive  diagnosis  can  only 
be  made  by  bringing  a  sound  or  catheter  in  contact  with  the  concretion. 
When  the  stone  is  situated  in  the  deeper  portions  of  the  organ,  it  will 


676  A  TEXT-BOOK   ON  SURGERY. 

escape  detection  by  this  method,  but  the  tumefaction  it  causes  may  be 
recognized  by  digital  exploration  'per  rectum,. 

The  interference  with  the  escape  of  urine  caused  by  calculi  of  the 
prostate  is  analogous  to  that  which  occurs  with  general  hypertrophy  of 
the  body  of  this  organ.  The  stream  of  iirine  is  diminished,  but  remains 
about  the  same  size,  and  escapes  steadily  throughout  the  act  of  urina- 
tion. There  is  no  sudden  and  complete  interruption  of  the  current,  as  in 
stone  in  the  bladder,  or  in  enlargement  of  the  middle  lobe  of  the  pros- 
tate. Calculi  of  this  organ  may  escape  into  the  urethra  and  lodge  there, 
or  work  their  way  back  into  the  bladder,  or  pass  out  at  the  meatus. 

The  treatment  is  palliative  until  operative  interference  is  necessitated 
on  account  of  dysuria.  An  exploration  should  be  made  by  the  supra- 
pubic incision  and  an  effort  made  to  remove  the  concretion  from  this 
side.  Failing  in  this,  a  perineal  incision  is  necessitated,  but  the  pros- 
tate should  not  be  incised  if  it  can  be  avoided.  The  stone  may  be 
removed  with  the  scoop  or  narrow  forceps. 

Neuralgia  of  the  prostate  and  neck  of  the  bladder  is  occasionally  met 
with.  Pain  is  present  in  this  organ  when  no  symptoms  of  inflammation 
are  discoverable.  It  is  usually  exaggerated  during  and  immediately 
after  micturition,  and  after  a  seminal  emission.  The  introduction  of  a 
sound  shows  great  tenderness  of  the  deep  urethra.  The  instrument  car- 
ried into  the  bladder  does  not  produce  the  tenesmus  and  pain  common 
to  cystitis.  An  examination  of  the  urine  will  demonstrate  the  absence  of 
pus,  which  will  also  serve  to  exclude  inflammation  of  the  bladder  or 
prostate.  The  causes  of  this  affection  are  as  a  rule  obscure.  Irregular 
or  excessive  venereal  indulgence  is  considered  to  be  one  of  the  most 
frequent  causes  of  neuralgia  in  this  organ.  The  treatment  involves  the 
removal  of  every  possible  source  of  irritation.  The  constitutional  meas- 
ures recommended  in  neuralgia  in  other  parts  of  the  body  should  be 
employed.  Locally  the  galvanic  current  is  especially  indicated.  If  the 
urine  is  extremely  acid  and  burning,  benefit  will  be  derived  from  the 
administration  of  large  quantities  of  alkaline  and  diluent  drinks. 


The  Ueethea. 

Urethritis. — Inflammation  of  the  urethra  may  be  traumatic  or  idio- 
pathic, specific  or  non-specific,  local  or  general.  Among  the  more  frequent 
causes  of  traumatic  urethritis  are  direct  violence  from  without,  applied 
to  the  perinseum  or  penis  ;  violent  and  excessive  sexual  intercourse  ;  the 
introduction  of  instruments  or  corrosive  substances ;  and  the  lodgment 
of  foreign  bodies  carried  in  from  without,  or  of  vesical  or  prostatic  cal- 
culi, etc.  It  is  usually  of  short  duration,  mild  in  character,  and  involves 
only  a  limited  portion  of  the  canal. 

The  treatment  demanded  is  rest,  the  removal  of  the  cause  of  the 
irritation,  and  the  dilution  of  the  urine  by  the  exhibition  of  alkalies 
and  diuretics. 

Specific  urethritis  (gonorrhoea)  is  a  violently  contagious  disease  afl:ect- 


URETHRITIS. 


677 


ing  the  mucous  membrane  of  this  canal,  at  times  extending  into  the 
bladder  and  seminal  vesicles,  and  along  the  vasa  deferentia  to  the  epi- 
didymis and  testicle. 

The  agent  of  contagion  is  now  believed  to  be  a  specific  micro-organ- 
ism, the  gonococcus.     If  the  purulent  discharge  of  an  acute  specific 

A  B 

''ht-'^'  A    ^  ^  ^  ^ 


Pare  culture  of  fronococ- 
ci.  Magnified  about 
seven  hundred  diam- 
eters.  (After  Bumm.) 


Development  of  gonococci 
by  division.  (After 
Bumm.) 


Epitbelia  studded  with  gonococci 
(Alter  Bumm  ) 


@) 


3--^  ^15^;;:^^- 


Section  through  mucous  membiane  of 
urethra,  demonstrating  gonococci  in 
the  tissues.  About  seven  hundred 
diameters.    (After  Bumm.) 


The  same.     (After  Bumm.) 


The  same,  in  advanced  stage  of  wide-spread  colonization  of  gonococci.     (After  Bumm.) 
Fio.  613  a. 

urethritis  is  examined  under  the  microscope,  in  the  pus  corpuscles 
chiefly  and  in  the  cast-off  epithelia  are  seen  numerous  dark  granular 
bodies  (Fig.  613  a).  The  epithelial  lining  of  the  urethra  and  the  peri- 
urethral tissues,  as  shown  in  Fig.  613,  F,  become  deeply  invaded  by 
these  organisms  where  they  rapidly  miiltiply,  producing  deep  and  wide- 
spread destructive  inflammatory  changes.  The  epithelia  are  destroyed 
and  cast  ofl' ;  schools  of  leucocytes  crowd  into  the  inflamed  area,  and 
are  thrown  off  in  the  transuded  liquor  pur  is.  As  the  intensity  of  the 
process  subsides,  repair  takes  place,  by  restoration  of  the  epithelial 
lining  in  mild  cases,  by  cicatrization  and  consequent  narrowing  of  the 
urethral  caliber  in  severe  cases,  producing  organic  stricture. 

The  demonstration  of  these  facts  in  the  pathology  of  specific  ure- 
thritis should  have  great  weight  in  the  application  of  the  therapeutic 
measures  to  this  disease,  for  it  is  evident  that  no  local  remedial  agent 
which  does  not  destroy  the  mucous  membrane  of  the  urethra,  and 
thereby  add  to  the  inflammatory  process,  can  destroy  the  cocci  imbedded 
in  the  submucous  tissues. 

When  the  virus  is  brought  into  contact  with  a  mucous  surface,  the 


678  A  TEXT-BOOK   ON   SURGERY. 

period,  of  time  whicli  elapses  before  the  local  symptoms  of  inflammation 
sire  noticeable  will  vary  in  different  individuals,  8.nd  even  in  the  same 
patient  at  different  inoculations.  It  is  very  j)robable  that  the  condition 
of  the  mucous  membrane  at  the  time  of  the  contact  has  more  to  do  with 
the  rapid  appearance  of  the  inflammation  than  any  variableness  in  the 
quality  of  the  virus.  The  period  of  incubation  may  range  from  a  few 
hours  to  several  days,  and  in  some  very  exceptional  instances  as  much  as 
two  weeks  have  elapsed  between  the  contact  and  the  recognition  of  the 
inflammatory  process.  The  limit  between  twenty-four  hours  and  three 
days  will  include  a  large  majority  of  cases  of  specific  urethritis. 

Usiially  the  earliest  symptom  of  gonorrhoea  is  a  burning  sensation  at 
the  meatus,  which  is  more  acute  as  the  urine  is  escaping.  The  lips  of  the 
meatus  soon  become  swollen  and  unusually  prominent  and  red.  If  care- 
fully separated,  a  film  of  muco-pus  will  be  seen  to  coat  over  the  mucous 
membrane. 

The  first  stage  of  the  disease  may  be  considered  as  beginning  with  the 
date  of  contact  with  the  virus,  and  ending  with  the  first  appearance  of 
the  suppuration.  The  average  duration  of  this  stage  is  from  two  to 
ten  days.  From  this  period  the  inflammatory  symptoms  increase  for 
from  three  or  four  days  to  as  much  as  two  weeks.  The  quantity  of  pus 
discharged  varies  from  a  few  drops  to  several  drachms  in  the  twenty-four 
hours.  It  is  increased  by  exercise  as  well  as  by  improper  diet.  The 
color  varies  from  the  bluish-white  hue  of  the  first  few  drops  to  the 
yellow  or  yellowish-green  tinge  of  that  discharged  during  the  height  of 
the  inflammatory  process.  In  some  instances  it  becomes  stained  with 
blood,  as  a  result  of  the  rupture  of  capillaries  in  the  engorged  mucous 
membrane. 

The  second  stage^  or  that  of  increasing  inflammation  and  suppura- 
tion, lasts  usually  about  twelve  days,  and  is  followed  by  the  third  stage, 
or  that  of  decreasing  inflammation  and  suppuration,  the  duration  of 
which  i^eriod  is  iisually  from  three  to  six  weeks. 

In  addition  to  the  purulent  discharge  and  the  pain  which  characterizes 
the  second  stage  of  this  disease,  there  is  also  a  diminution  in  the  size  of 
the  stream  of  urine,  due  to  the  swollen  and  puffy  condition  of  the  mucous 
membrane  of  the  urethra.  In  the  milder  forms  of  gonorrhoea  no  oth- 
er symptoms  are  present  in  the  second  stage.  Not  infrequently,  how- 
ever, the  inflammatory  process  extends  into  the  prostatic  urethra,  and 
thence  to  the  bladder  or  along  the  seminal  ducts  to  the  vesicles  and 
testes.  Infiltration  of  the  vascular  erectile  tissue  of  the  corpus  spon- 
giosum occurs  in  a  varying  degree  in  all  instances,  and  occasionally  the 
exudation  extends  into  the  corpora  cavernosa.  A  more  frequent  com- 
plication of  gonorrhoea  is  inflammation  of  the  glans  penis  {balanitis)  and 
of  the  prepuce  {posthitis),  due  not  only  to  the  mechanical  effects  of  the 
discharge,  but  to  direct  invasion  by  contagion.  As  a  result  of  such 
extensive  infiltration,  the  penis  is  subjected  to  various  deformities,  pain- 
ful in  an  extreme  degree,  and  not  without  danger  to  the  integrity  of 
this  organ. 

Chordee,  or  bowing  of  the  penis,  is  a  common  symptom.     The  organ 


URETHRITIS.  679 

is  in  part  or  wholly  erected,  and  on  account  of  the  injBltration  of  the 
vascular  spaces  of  the  corpus  spongiosum  with  the  embryonic  inflamma- 
tory tissue,  it  fails  to  expand  with  the  corpora  cavernosa. 

Balano-posthitis,  in  the  case  of  a  long  and  tightly  fitting  prepuce, 
becomes  at  times  an  annoying  if  not  a  serious  complication.  Complete 
phimosis  may  occur  as  a  result  of  the  swollen  condition  of  the  prepuce, 
or,  when  the  foreskin  is  slipped  behind  the  corona  glandis,  paraphimosis 
may  ensue.     If  not  relieved,  gangrene  in  most  cases  is  imminent. 

These  complications  are  as  a  rule  a  part  of  the  second  stage  of  gonor- 
rhoea, occurring  within  the  fu'st  eighteen  days  of  an  attack,  and  gradually 
disappearing  dming  the  third  stage. 

Pathology. — Strictly  speaking,  the  morbid  process  is  an  inflammation 
of  the  mucous  membrane  of  the  urethra  and  the  submucous  connective 
tissue.  The  extension  to  other  organs  is  purely  accidental.  It  com- 
mences at  the  meatus  and  travels  backward.  The  epithelium  is  swollen, 
there  is  marked  hyperasmia  of  the  submucous  tissue,  vrith  the  escape  of 
leucocytes  and  the  formation  of  the  common  embryonic  tissue  of  inflam- 
mation. In  milder  cases  the  products  of  inflammation  undergo  retro- 
gressive changes,  and  are  absorbed  ;  whUe  in  other  instances  connective- 
tissue  development  is  precipitated,  ending  in  cicatrization  and  the  forma- 
tion of  stricture.  The  organic  elements  of  gonorrhoeal  pus  are  leucocytes, 
embryonic  cells,  epithelia,  and  blood-coi-puscles. 

The  diagnosis  of  specific  urethritis  may  be  made  out  from  the  suc- 
cession of  symiDtoms  given.  It  can  rarely  be  mistaken.  It  is  at  times 
necessary  to  differentiate  gonorrhoea  from  simple  or  non-specific  urethri- 
tis. The  latter  disease  lacks  every  symptom  of  virulence  which  is  char- 
acteristic of  the  former.  "Within  the  first  few  days  of  an  attack  it  is  not 
always  easy  to  make  a  positive  diagnosis,  but  after  the  first  week  is  passed 
the  symptoms  are  evident. 

Treatment. — Gonorrhoea  is  a  self-limited  disease,  running  a  given 
course,  and  under  favorable  conditions  ending  in  recovery  without  the 
aid  of  medication. 

Efforts  to  abort  the  disease  by  the  injection  of  coiTosive  substances 
are  not  justifiable.  Any  substance  capable  of  desti'oying  the  virus  of 
gonorrhoea  is  also  capable  of  doing  damage  to  the  urethra,  more  serious 
in  its  consequences  than  those  of  the  worst  forms  of  the  disease  left  with- 
out medical  interference. 

When  specific  urethritis  is  recognized  in  its  earlier  stages,  the  pa- 
tient should  be  impressed  with  the  importance  of  rest,  and  the  regu- 
lation of  his  diet  and  manner  of  living.  It  is  important  that  the  danger 
of  inoculation  of  the  conjunctiva,  or  other  mucous  surfaces,  with  the 
virus,  should  be  emphasized.  If  necessity  compels  the  patient  to  take 
the  increased  risk  which  exercise  implies,  the  physician  should  relieve 
himself  of  this  much  of  responsibility  by  insisting  upon  the  minimum 
of  physical  exertion.  The  diet  should  be  nutritious  yet  simple,  and 
stimulating  beverages,  as  coffee  and  the  alcoholic  group,  should  be  for- 
bidden. Tea  is  not  so  objectionable  as  coffee,  excejDt  when  it  induces 
sleeplessness.     The  bowels  should  be  kept  open  by  the  use  of  fruits  and 


680  A  TEXT-BOOK   ON   SURGERY, 

the  administration  of  the  mild,  laxative  waters.  The  administration  of 
citrate  of  potash,  in  doses  of  grs.  xx,  four  or  five  times  a  day,  will  have  a 
beneficial  effect  upon  the  urine  and  the  urethra.  It  may  be  conveniently 
taken  in  a  glass  of  water  to  which  the  juice  of  half  a  lemon  has  been 
added.  A  hip-bath  in  warm  water  every  night  and  morning  not  only 
insures  a  degree  of  cleanliness  which  is  desirable,  but  is  not  without  value 
as  an  antiphlogistic. 

In  addition  to  these  general  features  of  treatment  to  be  carried  out 
during  the  first  and  second  stages  of  gonorrhoea,  certain  local  measures 
are  equally  important.  One  of  the  chief  of  these  is  to  secure  free  dis- 
charge of  the  pus  from  the  urethra  and  prepuce.  The  penis  should  be 
kept  pendent,  and,  if  possible,  the  prepuce  worn  so  as  to  leave  the  gland 
exposed.  The  common  practice  of  stuffing  a  piece  of  lint  or  a  tuft  of 
absorbent  cotton  over  the  meatus  and  beneath  the  prepuce,  and  then 
pressing  the  foreskin  over  this  to  hold  the  plug  in  place,  thus  stopping  up 
the  iirethra  when  free  drainage  is  essential,  and  holding  the  acrid  dis- 
charge in  contact  with  the  glans  and  prepuce  when  these  should  be  pro- 
tected, is  exceedingly  objectionable.  Scarcely  less  so  is  the  habit  of 
tying  rags,  lint,  or  cotton  about  the  penis,  for  these  dressings  interfere 
with  the  circulation  in  this  organ. 

A  bag  of  oiled-silk,  rubber  tissue,  or,  if  these  can  not  be  obtained,  of 
ordinary  cloth,  should  be  made  large  and  long  enough  to  fit  loosely  over 
the  penis.  It  is  held  in  place  by  strings  which  pass  up  to  a  belt  worn 
around  the  waist.  A  pellet  of  absorbent  cotton  in  the  bottom  of  this  bag 
suflaces  to  catch  the  pus  which  drips  from  the  meatiis.  It  is  usually 
necessary  to  have  two  of  these  bags,  for  purposes  of  cleanliness.  The 
various  complications  of  gonorrhoea,  as  cystitis,  prostatitis,  epididymitis, 
orchitis,  etc.,  have  been,  or  will  be,  considered  under  their  respective 
heads. 

For  the  control  or  relief  of  chordee  the  following  rule  of  practice  will 
suffice  :  The  patient  should  be  advised  to  refrain  from  sleeping  on  the 
back,  and  should  be  directed  to  empty  his  bladder  at  more  frequent  in- 
tervals than  ordinary.  When  the  attack  is  precipitated,  standing  with 
the  naked  back  in  contact  with  the  wall,  or  some  cold  surface,  will  often 
cause  the  erection  to  disappear.  The  same  may  be  said  of  the  local  use 
of  ice  or  cold  water.  A  full  dose  of  bromide  of  potassium  and  chloral- 
hydrate  at  bedtime,  and  repeated  at  intervals,  if  necessary,  is,  however, 
the  surest  way  to  control  the  more  annoying  and  obstinate  cases. 

Injections  of  the  ui-ethra  in  gonorrhoea  should  be  made  with  great  care. 
They  are  contra-indicated  in  the  acute  inflammatory  and  suppurative 
stages  of  this  disease.  Deep  injections,  which  necessitate  the  introduction 
of  a  catheter  down  to  the  cut-off  muscle,  are  not  advisable.  The  germs  of 
this  disease  are  in  great  part  lodged  in  the  sub-mucoiis  tissues  and  be- 
yond the  contact  of  any  agent  intended  for  their  destruction.  The  harm 
done  by  the  invasion  with  a  foreign  body  is  not  counterbalanced  by  any 
good  effect  of  the  injection.  Usually,  from  the  tenth  to  the  twentieth 
day  after  suppuration  is  noticed,  if  the  foregoing  measures  have  been 
faithfully  carried  out,  the  character  of  the  discharge  is  changed  from  the 


SPECIFIC    URETHRITIS.  6S1 

yellow,  thick,  and  profuse  pns  of  acute  gonorrlioea,  to  the  scant,  wMtish, 
milky  fluid  of  the  later  stages  of  the  inflammation,  and,  with  this,  the 
painful  symptoms  hare  also  disappeared.  It  is  not  until  this  period  is 
reached  that  the  use  of  an  injection  should  be  entertained.  Xitrate  of 
silver,  locally  applied,  possesses  more  curative  properties  than  any  other 
agent,  but  it  is  objectionable  on  account  of  the  discoloration  it  produces. 
The  injection  which  is  least  objectionable  is  composed  of  acetate  of  zinc 
in  dilute  solution  of  subacetate  of  lead.     From  gr.  j  to  iij  of  the  zinc 

may  be  used  to  sj  of 
the  lead  solution.  The 
weaker  preparation  is  in 
general  to  be  preferred, 
ibr  gonorrhoea.  ^he    urethi-al     syringe 

should  be  selected  with 
great  care.  Fig.  614  represents  a  proper  instrument.  It  contains  about 
3  ij,  has  a  conical  nozzle,  and  can  be  used  with  one  hand.  The  long-noz- 
zled,  pointed  syringe  should  never  be  employed.  In  its  use  the  point 
strikes  against  the  mucous  membrane,  causing  an  exaggeration  of  the  in- 
flammatory process  at  this  point,  not  infrequently  resulting  in  stricture. 
An  injection  should  be  performed  as  follows,  and  each  patient  should 
be  thoroughly  schooled  before  he  is  intrusted  with  its  employment  upon 
himself :  The  bladder  should  not  be  emptied.  The  bottle  containing  the 
injection-fluid  should  be  shaken,  and  a  quantity  sufiicient  to  iill  the 
syringe  twice  emptied  into  a  cup,  and  drawn  into  the  instrument  as 
needed.  The  syringe  is  now  held  with  the  point  upward,  and  the  piston 
pushed  up  until  the  air  which  may  have  entered  with  the  fluid  is  expelled. 
A  small  quantity  of  oil  or  vaseline  is  rubbed  upon  the  tip  of  the  syringe. 
the  patient  lies  upon  his  back,  the  glans  penis  is  held  between  the  fingers 
of  the  left  hand,  and  the  index-finger  is  carried  through  the  ring  on  the 
end  of  the  piston,  while  the  cylinder  is  grasped  between  the  thumb  and 
middle  finger.  The  conical  end  of  the  syringe  is  now  inti'oduced  into  the 
meatus,  and  pressed  in  with  sufficient  firmness  to  prevent  the  escape  of 
the  fiuid  while  the  contents  of  the  cylinder  are  slowly  emptied  into  the 
urethra.  With  a  syringe  of  this  capacity  there  is  little  danger  of  over- 
coming the  resistance  of  the  compressor-muscle,  and  thus  forcing  the 
injection-material  back  into  the  bladder.  Should  this  accident  occur,  the 
urine  which  is  in  this  organ  will  dilute  the  zinc  so  freely  that  its  irritating 
properties  will  be  lost.  In  making  an  injection  the  urethra  should  be 
well  distended,  so  that  aU  parts  of  the  mucous  surface,  as  well  as  the  fol- 
licles, may  be  brought  in  contact  with  the  fluid.  After  holding  the  injec- 
tion in  the  urethra  for  from  one  to  three  minutes  it  may  be  allowed  to 
run  out,  and  the  patient  directed  to  empty  his  bladder.  A  second  quan- 
tity, about  one  third  less  than  the  first,  is  again  injected.  These  injec- 
tions should  be  repeated  night  and  morning,  and,  if  convenient,  at  noon. 
Upon  the  supervention  of  any  marked  symptoms  of  irritation,  as  cystitis 
or  an  increase  of  the  urethral  inflammation,  or  epididymitis,  etc.,  they 
should  be  immediately  discontinued.  The  period  in  the  history  of  a 
gonorrhoea  when  internal  medication  mav  be  used  with  advantage  varies 


682  A  TEXT-BOOK   ON   SURGERY. 

from  the  third  to  the  fifth  week  of  the  disease.  In  the  acute  stages, 
while  the  inflammatory  symptoms  are  prominent,  they  are  contraindi- 
cated.  The  oil  of  sandal-wood  and  balsam  of  copaiba  are  the  more  useful 
remedies  of  this  class.  The  former,  in  doses  of  five  to  ten  drops,  from 
five  to  ten  times  a  day,  is  more  readily  borne  by  the  stomach,  and  does 
not  cause  the  rash  which  not  infrequently  follows  the  administration  of 
copaiba.  These  remedies,  however,  very  often  can  not  be  taken,  and 
should  not  be  persisted  in  when  they  interfere  with  the  functions  of  the 
stomach.  Even  when  thus  carefully  managed,  the  annoying  symptoms 
of  gonorrhoea  continue  for  from  four  to  eight  weeks,  and  in  most  cases 
there  is  a  slight  watery  or  mucous  discharge  for  several  weeks  after  the 
case  passes  out  from  the  immediate  notice  of  the  practitioner.  Upon  the 
whole,  the  effect  of  treatment  upon  the  duration  of  this  disease  is  not 
entirely  satisfactory. 

Among  the  unpleasant  complications  of  gonorrhoea  are  balanitis,  pos- 
thitis, paraphimosis,  prostatitis,  cystitis,  epididymitis,  orchitis,  bubo, 
ophthalmia,  and  retention  of  urine. 

Balanitis  and  posthitis,  inflammation  of  the  glans  and  prepuce,  are 
conditions  existing  in  a  varying  degree  in  almost  all  cases  of  gonorrhoea. 
Among  the  cii'camcised,  or  those  with  short  and  retracted  foreskins, 
posthitis  need  not  occur,  but  the  acrid  discharge  will  always  affect 
the  epithelial  covering  of  the  glans  in  the  immediate  neighborhood  of 
the  meatus.  When  the  foreskin  is  long  and  adherent,  or  not  readily 
drawn  behind  the  glans,  it  usually  becomes  swollen  and  tense,  retains 
the  irritating  discharge,  and  inaugurates  an  exceedingly  painful  and 
annoying  condition  of  phimosis.  Even  when  thus  .swollen,  if  the  pre- 
puce can  be  retracted,  it  is  apt  to  be  caught  behind  the  corona  and 
become  irreducible,  with  ensuing  strangulation,  if  not  relieved  by  oper- 
ative interference.  Preputial  sloughing  will  occur  in  a  certain  propor- 
tion of  neglected  cases. 

In  the  treatment  of  gonorrhoea  certain  measures  were  detailed  looking 
to  the  prevention  of  these  complications.  When,  however,  they  are 
present  in  a  mild  degree,  balanitis  and  posthitis  disappear  with  proper 
attention  to  cleanliness.  The  glans  and  prepuce  shoiild  be  irrigated  by 
being  submerged  in  a  vessel  of  warm  water.  Soap  should  not  be  em- 
ployed. The  hip-bath,  already  given  as  useful  in  the  general  management 
of  the  disease,  is  especially  so  in  this  complication. 

The  inflammatory  phimosis  of  gonorrhoea,  as  of  non-specific  halano- 
postMtis,  demands  active  measures  of  treatment.  In  milder  cases  it  may 
suffice  to  maintain  cleanliness  by  the  frequent  sub-preputial  injection  of 
tepid  water.  For  tliis  jDurpose  a  syringe  with  a  delicate  dull  point  or 
nozzle,  about  an  inch  in  length,  is  needed.  It  should  be  oiled,  carefully 
introduced  between  the  glans  and  prepuce,  and  the  contents  slowly  dis- 
charged. An  irrigating  apparatus  may  also  be  attached  to  the  nozzle, 
and  a  continuous  current  apiDlied,  which  does  away  with  the  irritation  of 
repeated  introductions  of  the  nozzle.  If  these  milder  measures  do  not 
relieve  the  pain,  tension,  and  threatened  strangulation,  an  incision  should 
be  made.     The  pi'epuce  may  be  nicked  in  several  places,  or  a  director 


BALANITIS. 


683 


introduced  in  tlie  median  line  above,  along  the  groove  of  wMcli  a  bistoury 
is  carried,  and  the  division  eflFected. 

When  inflammatory  paraphimosis  exists,  adhesions  rapidly  occur  at 
a  point  just  behind  the  corona,  on  the  dorsum  penis,  rendering  a  reduc- 
tion impossible  unless  these  transverse  bands  are  divided.  The  reduc- 
tion of  a  paraphimosis  is  undertaken  in  this  manner :  The  organ  is  held 
in  a  vessel  of  cold  water  for  a  few  minutes,  or  cold  cloths  are  wraj^ped 
loosely  over  and  around  the  swollen  parts.  When  removed,  the  glans 
and  prepuce  are  thoroughly  lubricated,  and  the  organ  grasped  so  that 
while  the  soft  parts  of  the  thumbs  press  the  glans  backward,  the  fingers 
are  drawing  the  prepuce  to  the  front.  Or  the  penis  may  be  grasjied 
by  the  thumb  and  finger  of  the  left  hand,  and  the  foreskin  di'awn  for- 
ward whUe  the  glans  is  pushed  backward  by  the  thumb  and  fingers  of 
the  opposite  member.  When  the  reduction  is  accomplished,  the  patient 
should  be  directed  to  make  every  effort  to  prevent  a  recurrence  of  the 
accident. 

If  the  efforts  at  reduction  fail,  the  contractions  on  the  dorsum,  behind 
the  glans,  should  be  divided  by  one  or  more  incisions  in  the  long  axis  of 
the  penis.  (Edema  of  the  prej)uce,  esi)ecially  of  the  lower  portion,  is  apt 
to  occur,  even  in  cases  of  recent  parai^himosis,  and,  when  the  condition 
has  existed  for  a  day  or  two,  infiltrations  occur,  which  may  persist  for  a 
long  time  after  the  constriction  is  relieved. 

Prostatitis  and  cystitis,  occurring  with  gonoiThoea,  require  treatment 
not  differing  from  that  already  given.  Retention  must  be  relieved  by 
the  small  soft  catheter,  or  by  supra-pubic  aspiration.  Epididyrnitis,  or 
inflammation  of  the  vas  deferens  and  the  globus  major  and  minor,  is  one 
of  the  most  iiainful  complications  of  gonorrhoea.  Perfect  physical  qiiiet, 
with  support  of  the  scrotum  and  testicle,  are  essential.  The  last  of  these 
measures  may  be  secured  by  using  the  handkerchief  sling,  which  is  made 
as  follows  : 

Attach  a  belt  or  piece  of  roUer  around  the  waist,  above  the  pelvis ; 
fold  a  good-sized  silk  handkerchief  in  a  triangular  shape,  cari-y  the  cen- 
ter of  the  long  side  of  this  tri- 
angle beneath  the  scrotum,  at 
the  perineo-scrotal  junction, 
attach  one  of  the  long  ends  to 
the  belt,  near  the  anterior  su- 
perior spine  of  the  ilium,  on 
either  side,  and  bring  the 
short  piece  directly  upward, 
in  front  of  the  scrotum  and 
penis,  and  pin  it  to  the  belt 
in  the  median  line  ;  or  the 
ends  may  be  tied  just  above 
the  root  of  the  penis  (Figs. 
615,  616). 
Another  method  is  to  place  a  three-cornered  cushion  beneath  the 
scrotum,  close  up  to  the  perinseum,  and  allow  the  testicles  to  rest  upon 


/I  / 

Fig.  615.  Fig.  616. 

Handkerchief  suspensory.     (After  Hill.) 


684  A  TEXT-BOOK  ON  SURGERY. 

this  support ;  or  two  thickly  folded  towels  may  be  pinned  together  and 
carried  tightly  around  the  thighs,  at  the  level  of  the  perineeum. 

At  times  the  tension  of  the  parts  is  so  great  that,  not  only  to  relieve 
pain,  but  to  prevent  suppuration  or  possible  gangrene,  puncture  or  in- 
cision is  imperative.  The  most  immediate  relief  will  follow  this  opera- 
tion. A  sharp  narrow  blade  is  preferable,  and,  if  the  instrument  is  not 
made  for  this  especial  purpose,  it  may  be  extemporized  by  projecting  the 
point  of  an  ordinary  sharp-pointed  bistoury  half  an  inch  beyond  the 
surface  of  a  cork  through  which  the  knife  is  thrust.  With  this  guard 
attached,  the  punctures  may  be  made  rapidly  and  without  danger  of 
penetrating  too  deeply. 

Although  the  procedure  is  very  painful,  it  is  usually  so  rapidly  ac- 
complished that  an  anaesthetic  is  not  necessary.  The  injection  of  a  2-per- 
cent cocaine  solution  will  aiford  a  fair  degree  of  anaesthesia.  The  opera- 
tor holds  the  scrotum  and  testicle  so  as  to  make  tense  the  skin  over  the 
epididymis  and  to  expose  it  properly  to  view,  and  then  by  well-directed 
and  rapid  thrusts  punctures  the  organ  in  from  two  to  four  or  six  points, 
scattered  over  the  induration.  A  free  discharge  of  dark  or  black  blood 
usually  follows,  and  in  from  twenty  to  thirty  minutes  the  pain  is  greatly 
if  not  entirely  relieved.  The  antiseptic  precautions  should  be  carried 
out  in  this  procedure. 

Partial  or  complete  orchitis  is  not  infrequent  in  gonorrhoea  with  epi- 
didymitis. The  treatment  is  in  general  similar  to  that  of  the  last-named 
disease.  The  diagnosis  is  readily  made  out  by  the  touch,  for,  when  hy- 
drocele does  not  coexist,  the  induration  of  the  organ  can  not  well  be 
mistaken.  Poultices  of  tobacco  have  long  enjoyed  a  reputation  in  the 
treatment  of  orchitis  and  epididymitis,  but  when  warm  applications  are 
indicated,  well-saturated  and  frequently  changed  warm  cloths  will  be 
found  equally  satisfactory  in  the  effect  produced,  and  much  more  cleanly 
than  the  poultices.  In  the  majority  of  instances^  cold  will  be  more  agree- 
able than  heat.  The  ice-bag  may  be  utilized  in  the  following  manner  with 
great  satisfaction :  A  bladder  or  rubber  bag  is  filled  with  crushed  ice, 
placed  upon  the  three-coi'nered  jierineal  cushion,  and  the  inflamed  organ 
allowed  to  rest  upon  it.  If  the  cold  is  too  great  for  comfort  (and  the 
patient  may  usually  be  relied  upon  to  determine  this),  a  layer  or  two  of 
lint  or  cotton  may  be  interposed.  It  occasionally  becomes  necessary 
to  puncture  or  incise  the  tunica  albuginea  in  orchitis  somewhat  after 
the  fashion  given  in  puncture  for  epididymitis.  Two  methods  are  em- 
ployed, namely:  to  carry  a  sharp-pointed,  long  knife  through  a  single 
puncture  of  the  scrotum  down  'to  the  testicle,  and  incise  the  fibrous  cap- 
sule in  one  or  more  places  parallel  with  its  long  axis  and  along  its  an- 
terior surface  ;  or  to  use  an  instrument  similar  to  that  employed  in  epi- 
didymitis, and  make  several  punctures  through  the  scrotum  and  the 
anterior  portion  of  the  capsule. 

Ingtdnal  adenitis^  or  &m&o,  occurs  in  a  considerable  proportion  of 
cases  of  specific  urethritis,  and  is  apt  to  be  bilateral.  The  disease  is 
readily  recognized  by  the  swelling  in  the  groin.  The  infiammatory 
process  is  usually  so  rapid  in  its  invasion  that  the  different  glands  in 


GONORRHCEAL  RHEUMATISM.  685 

tliis  group  of  lympliatics  can  not  be  made  out,  the  entire  gronp  being 
matted  together  in  one  mass  of  embryonic  cells  infiltrating  the  tissues 
around  the  glands  as  well  as  involving  theu-  substance.  The  gonorrhcpal 
bubo  tends  naturally  to  suppui-ation.  In  mild  cases,  and  where  the 
proper  measures  are  taken  at  the  early  appearance  of  the  adenitis,  this 
disaster  may  be  averted  ;  but  in  others,  partly  owing  to  the  unfavorable 
condition  of  the  tissues  and  to  the  continued  irritation  from  motion,  pus- 
foi-mation  can  not  be  prevented. 

In  the  treatment  of  acute  inflammatory  bubo,  perfect  rest  is  impera- 
tive, and  the  dorsal  decubitus  should  be  maintained.  Local  medication 
is  of  little  value.  The  employment  of  cold  will  be  found  agreeable  in 
the  earlier  stages,  and  may  serve  to  prevent  suppuration.  The  ice-bag 
may  be  employed  by  laying  it  upon  a  cii-cular  pad  placed  aroiuid  the 
bubo.  In  this  way  the  pressure  is  entirely  taken  off  the  inflamed  sur- 
face. After  the  formation  of  pus  is  inevitable,  warm  cloths  or  poultices 
should  be  substituted.  "When  pus  is  formed,  a  free  incision  under  co- 
caine anaesthesia  should  be  made. 

Chronic  suppurative  adenitis  of  the  inguinal  glands  occasionally  per- 
sists long  after  the  gonon-hcea  which  caused  it  has  disappeared.  The 
only  remedy  is  to  dissect  out  the  diseased  glands  with  the  curved  scis- 
sors, or  scrape  them  out  vdth.  Yolkmann's  spoon. 

Gonovvh.(ssl  proctitis  is  a  rare  affection,  and  does  not  call  for  especial 
consideration. 

Ophthalmia,  resulting  from  the  inoculation  of  the  conjunctiva  with 
the  virus  of  specific  urethritis,  has  been  considered  with  lesions  of  the  eye. 

Gonorrhosal  Rheumatism. — In  a  certain  proportion  of  individuals 
suffering  from  gonorrhceal  inoculation  at  a  period  varying,  from  five  or 
six  days  to  several  weeks  from  the  date  of  the  attack,  symptoms  not  un- 
like those  occurring  in  gout  or  rheumatism  make  their  appearance  in 
the  joints,  tendons,  and  bursfe,  and  less  frequently  in  the  neiwes  and 
eye.  The  parts  involved  become  more  or  less  swollen  and  painful.  The 
pain,  however,  is  less  than  in  ordinary  rheumatism.  The  febrile  move- 
ment is  not  high,  and  the  character  of  the  urine  is  unchanged,  in  both 
of  which  features  it  differs  from  ordinary  rheumatism  (Foumier).  T^eu- 
ralgia  occasionally  supervenes  in  the  course  of  this  disease.  In  a  certain 
proportion  of  cases  the  eye  is  affected,  but  the  ophthalmia  here  in  no 
ways  resembles  that  of  gonorrhoeal  conjunctivitis.  The  pathology  of 
this  disease  is  not  understood,  and  the  treatment  is  entirely  expectant. 

Gonorrhoea  in  females  is  usually  less  severe  than  with  males,  and 
yields  more  readily  to  treatment.  The  chief  seat  of  the  inflammation  is 
in  the  vagina.  The  urethra  and  bladder  may  also  become  involved.  In 
the  treatment,  quiet  is  of  first  importance.  The  warm  hip-bath  should^ 
be  employed  several  times  a  day,  and  the  vagina  irrigated  at  regular  in- 
tervals with  warm  water  thrown  in  from  a  fountain-syringe.  As  soon 
as  the  acute  symptoms  have  subsided,  injections  of  dilute  subacetate  of 
lead,  with  acetate  of  zinc  (grs.  ij-iv  to  3  j),  should  be  employed. 

Simple  Urethritis. — There  is  occasionally  met  with  in  practice  an 
acute  inflammation  of  the  urethra,  attended  by  a  slight  muco-purulent 


686  A   TEXT-BOOK    ON   SURGERY. 

discharge,  in  patients  who  have  not  been  subjected  to  the  specific  con- 
tagion of  gonorrhoea.  It  is  well  established  that  urethritis  in  the  male 
may  be  caused  by  exposure  to  cold,  and  by  the  irritation  of  a  vaginal 
or  uterine  discharge  in  a  woman  not  affected  with  gonorrhoea.  Simj^le 
urethritis  differs  in  many  respects  from  the  specific  disease.  In  color, 
the  pus  is  white,  and  in  consistency  it  is  thinner,  and  resembles  rather 
the  discharge  of  gleet.  The  itching  or  burning  sensation  of  the  more 
violent  affection,  if  not  entirely  absent,  is  much  less  annoying  in  simple 
urethritis. 

Chordee,  epididymitis,  orchitis,  and  cystitis  are  rarely  present,  and, 
when  occurring,  are  milder  in  degree  than  when  these  affections  compli- 
cate a  gonorrhoea.  The  history  of  the  disease  is  short,  even  when  left 
without  treatment.  In  the  treatment  of  simple  urethritis,  mild  astrin- 
gent injections  are  usually  indicated  in  the  earlier  stages  of  the  inflam- 
mation, unless  the  process  is  more  than  ordinarDy  violent,  under  which 
conditions  the  measures  advised  for  the  first  stage  of  specific  urethritis 
should  be  adopted.  The  warm  hip-bath  should  be  advised,  and  alkaline 
drinks  administered.  Dilute  subacetate  of  lead,  5  h  "with  acetate  of  zinc, 
gr.  j,  will  be  about  the  proper  strength  for  the  injection.  The  oil  of 
sandal-wood  should  be  given  after  the  fourth  or  fifth  day.  The  duration 
of  simple  urethritis  varies  from  three  or  four  days  to  two  weeks. 

Gleei,  or  Ghronic  Urethritis. — Gleet  is  a  name  given  to  the  j^rolonged 
discharge  from  the  urethra  of  a  variable  quantity  of  muco-purulent, 
bluish-white  fluid.  This  discharge  is  a  transudation  from  the  mucous 
and  glandular  epithelia  of  the  urethra.  In  gleet,  all  or  any  limited 
portion  of  this  tube  may  be  affected.  The  pathological  change  is  a  puf- 
finess  of  the  lining  membrane,  due  to  hypersemia  of  the  sub-epithelial 
vascular  area,  with  a  tendency  to  embryonic  and  connective-tissue  for- 
mation. In  some  points  patches  of  erosions  or  tissue-necrosis  occur. 
The  epithelia  lining  the  glandular  aj^paratus — as  those  of  the  prostate, 
Cowper's  glands,  and  the  urethral  follicles— become  more  or  less  in- 
volved. Not  infrequently  the  outlets  to  these  follicles  become  ob- 
structed by  the  superficial  infiammatory  process,  resulting  in  the  forma- 
tion of  one  or  more  retention- cysts,  which  project  into  the  lumen  of 
the  tube. 

Any  form  of  acute  urethritis  may  pass  into  this  chronic  condition  of 
gleet,  or  a  urethritis,  subacute  in  its  character  from  the  beginning,  may 
continue  as  a  gleet. 

Although  chronic  urethritis  may  exist  without  the  presence  of  strict- 
ure of  the  urethra— as  in  follicular  urethritis— the  exceptions  to  this 
rule  are  extremely  rare.  Any  chronic  interference  with  the  normal  cali- 
ber of  the  urethra  serves  to  induce  a  catarrhal  condition  of  the  mucous 
membrane  of  this  canal,  which,  commencing  near  the  seat  of  stricture, 
may  involve  any  portion  of  the  tube. 

The  treatment  of  gleet  involves,  primarily,  the  removal  of  the  cause. 
Taldng  stricture  as  the  chief  cause,  urethrotomy  with  dilatation,  or  dila- 
tation without  cutting,  is  demanded.  In  mild  cases  without  close  organic 
stricture,  the  introduction  of  the  steel  sound  will  often  effect  a  cure. 


STRICTURE    OF   THE   MALE   URETHRA.  687 

The  metliods  of  procedure  Avill  be  given  in  full  in  the  treatment  of  strict- 
ure of  the  urethra. 

In  chronic  follicular  urethritis  a  most  excellent  method  of  treatment 
is  the  application  of  cold  by  means  of  the  double  closed  silver  catheter 

(Fig.  617j.  This  instru- 
ment has  the  ordinary 
ciu've  of  the  male  cathe- 
ter, is  hoUow,  with  a  cen- 
tral partition  which  does 

Fig.  617. — Double-current  closed  catheter  for  applying  not    Quite    extend    tO    the 

cold  to  the  urethra.  '  ^ 

tip,  and  it  is  completely 
closed,  so  that  the  water 
passes  down  one  side  and  up  the  other  without  coming  in  contact  with 
the  mucous  membrane. 

It  is  advisable  to  employ  a  catheter  large  enough  to  fairly  distend 
the  urethra.  J^os.  14,  16,  and  18  (U.  S.  scale)  will  be  more  generally 
useful.  It  should  be  oiled  and  introduced  as  far  back  as  the  pros- 
tatic urethra.  A  rubber  tube  leading  from,  an  irrigator  filled  with 
cracked  ice  and  water  is  attached  to  one  of  the  two  outer  mouths  of  the 
catheter.  A  second  tube  is  fastened  to  the  other  opening  and  leads  into 
a  basin.  The  water  is  turned  on  slowly  at  first,  and  is  allowed  to  run 
in  from  five  to  ten  minutes,  and  the  catheter  is  then  removed.  The 
sensation  is  slightly  painful  for  a  few  seconds,  but  anaesthesia  soon  su- 
pervenes. The  operation  may  be  repeated  in  from  three  to  six  days. 
If  the  reaction  is  severe,  the  interval  may  be  longer  between  the  appli- 
cations. 

Stricture  of  the  Male  UretJira. — Strictures  of  the  urethra  may  be 
divided  into  two  classes  :  true  or  organic,  and  false  or  spasmodic. 

A  permanent  diminution  of  the  caliber  of  this  canal,  as  a  result  of  an 
inflammatory  process,  constitutes  a  true  or  organic  stricture.  A  spas- 
modic stricture  exists  when  the  normal  caliber  is  diminished  as  a  result 
of  contraction  of  the  voluntary  or  involuntary  muscular  elements  con- 
nected with  the  urethra. 

Congenital  non-inflammatory  narrowing  of  the  meatus  does  not 
constitute  a  stricture.  The  normal  contraction  of  the  compressor-ure- 
thrse  or  "  cut-off "  muscle  is  also  excluded  in  the  definition  of  spas- 
modic stricture. 

An  organic  stricture  may  be  annular,  tortuous,  single,  or  multiple. 

In  annular,  or  ring  stricture,  the  cicatricial  contraction  involves  the 
entire  circumference.     It  may  vary  in  width  from  a  Kne  to  one  inch. 

In  tortuous,  or  irregalar  stricture,  an  inch  or  more  of  the  urethral 
canal  is  involved. 

Two  or  mors  annular  or  lateral  strictures  may  unite  to  form  a  tortu- 
ous or  irregular  stricture. 

The  patliology  of  stricture  of  the  urethra  is  that  of  an  inflammation 
of  variable  intensity  involving  the  epithelial  and  submucous  basement 
membrane  of  this  canal,  together  with  the  deeper  tissues  of  the  corpus 
spongiosirm,  and  occasionally  of   the  corjDora  cavernosa.     This  process 


688  A  TEXT-BOOK   ON  SURGERY. 

usually  begins  from  within,  but  may  originate  in  tlie  deeper  tissues  of 
the  penis  and  involve  the  urethra  secondarily. 

In  a  typical  case  there  is  first  an  increased  vascularity  of  the  submu- 
cous area,  followed  by  emigration  of  leucocytes  and  cell-proliferation. 
The  lining  membrane  becomes  puffy  and  swollen,  and  the  diameter  of 
the  canal  is  diminished.  As  the  acute  inflammation  subsides,  the  puffi- 
ness  disappears,  but  the  caliber  of  the  tube  is  again  diminished  by  the 
contraction  which  takes  place  in  the  newly  formed  connective-tissue  ele- 
ments (cicatrization). 

Causes.  — Among  the  causes  of  stricture,  specific  urethritis  ranks  first, 
and  it  is  highly  probable  that  the  precedence  which  gonorrhoea  enjoys 
in  the  getiology  of  stricture  is  due  rather  to  the  improper  management 
of  the  urethritis  than  to  the  eiiects  of  the  inflammation  proper.  The 
employment  of  corrosive  and  irritating  injections,  the  introduction  of 
instruments  (syringe-nozzles,  bougies,  etc.)  upon  an  inflamed  surface,  to- 
gether with  the  unnecessary  exposure  of  the  person  in  the  uninterrupted 
pursuit  of  business  or  pleasure,  combine  to  make  gonorrhcBa  one  of  the 
most  dangerous  of  the  venereal  diseases. 

Any  violence  inflicted  uj)on  the  urethra,  either  from  without,  as  by  a 
blow  upon  the  perineeum  or  penis,  or  from  within,  as  by  the  reckless 
use  of  instruments,  the  lodgment  of  calculi  or  other  foi'eign  bodies,  may 
also  cause  a  stricture. 

Chancroidal  ulcer  within  the  meatus  is  a  rare  cause  of  this  lesion. 
Certain  medicines,  as  cantharides,  if  administered  in  large  doses  and  for 
a  prolonged  period,  induce  inflammation  of  the  urinary  tract,  and  thus 
may  cause  stricture. 

Location. — The  most  frequent  seat  of  organic  stricture  is  in  that 
portion  of  the  urethra  limited  behind  by  the  compressor-ure three  mus- 
cle, and  in  front  by  the  suspensory  ligament  at  the  junction  of  the  penile 
with  the  perineal  urethra.  Next  in  order  is  the  first  inch  within  the 
meatus.  Stricture  in  the  prostatic  portion  is  rare.  As  stated  in  the 
consideration  of  diseases  of  the  prostate,  it  may  occur  in  general  hyper- 
trophy of  this  organ. 

Diagnosis. — The  symptoms  of  stricture  are  a  gleety  discharge,  inter- 
ference with  the  escape  of  iirine  or  semen,  and  pain.  A  muco-purulenx 
discharge  continuing  for  several  months  is  almost  pathognomonic  of  this 
lesion,  and  justifies  exploration  in  order  to  determine  the  j)resence  of 
stricture.  Interference  with  the  escape  of  urine  from  the  bladder  when 
atony  of  this  organ  and  hypertrophy  of  the  prostate  are  eliminated,  are 
also  symptoms  of  imiDortance.  A  twisted  or  forked  stream,  when  not  of 
diminished  volume,  has  no  significance,  for  this  may  exist  with  a  per- 
fectly normal  canal.  Pain  is  not  often  a  symptom  of  organic  stricture^ 
but,  when  present,  is  not  without  value  as  an  indication  of  localized  in- 
flammation. 

No  matter  what  symptoms  may  exist,  a  diagnosis  can  only  be  arrived 
at  by  instrumental  exploration,  which  can  be  done  without  pain,  and 
by  which  means  the  exact  location  and  character  of  the  stricture  can  be 
made  positive. 


STRICTURE   OF  THE  MALE   URETHRA.  689 

For  this  purpose  the  bulbous  bougie  is  invaluable.   These  instruments 

are  of  two  kinds — the  elastic  or  gum  bougie  of  Dick  (Fig.  618),  and  the 

oval-tipped  wire  bougie  of  Otis  (Fig.  619).     They  should  be  made  of  all 

sizes,  commencing  with  ~No.  6  and  ending  with  Nos.  21  or  23 

^        (U.  S.  scale).     For  practical  purjDoses  every  alternate  size,  from 

Nos.  6  to  23  inclusive,  will  suffice.     The  gum  bougie  is  a  safer 


Fig.  619. — Otis's  oval-tipped  wire  bougie,  for  locating  strictures  of  the  urethra. 

instrument  than  that  composed  of  metal,  since  it  is  incapable  of 
doing  harm  under  any  cii-cumstances.  It  is  objectionable,  how- 
ever, on  account  of  its  liability  to  be  spoiled  by  heat,  and  of 
becoming  fragile  from  age.  It  should  always  be  slowly  warmed 
to  about  the  temperature  of  the  body  before  being  introduced. 
The  wire  bougies  are  thoroughly  satisfactory  instruments,  and 
incapable  of  injury  to  the  urethra  if  ordinary  care  is  taken. 
The  bulbs  are  oval,  the  wire  is  flexible,  and  is  screwed  into  the 
bulb  for  security.  The  sizes  are  the  same  as  for  the  gum  bougies 
just  given. 


Fig.  620. — Longitudinal  section  of  the  urethra,  showing  the  diameter  of  the  canal  at  TariouB 
points,    a,  Prostatic;   b,  membranous;   c,  penile  portion.     (After  Thompson.) 

In  the  effort  to  locate  a  stricture,  the  different  diameters  of  the 
normal  urethra  at  various  points  in  this  canal  must  be  borne  in 
mind.  The  meatus  is  least  dilatable,  and  the  membranous  por- 
\  tion  next  in  order.  Immediately  behind  the  meatus  there  is  an 
Fig  618.  Gxpausiou  iuto  the  fossa  navicularis,  and  from  this  point  to  the 
Dick's  suspensory  ligament  (the  junction  of  the  penile  and  j^erineal 
bfu^e,  urethra),  the  diameter  is  about  the  same.  From  the  suspensory 
o%^'\ip.  ligament  to  the  anterior  layer  of  the  triangular  Kgament,  the 
diameter  gradually  increases.  This,  the  bulbous  portion,  is  the 
largest  part  of  the  canal.  Behind  the  membranous  portion  there  is  a 
second  expansion  in  the  prostate  (Fig.  620). 

The  patient  should  be  placed  upon  the  table  or  bed  in  the  dorsal 
decubitus.  In  order  to  secure  insensibility,  from  twenty  to  thirty  minims 
of  a  4-per-cent  solution  of  cocaine  should  be  thrown  into  the  urethra. 

44 


690  A  TEXT-BOOK  ON  SURGERY. 

This  may  be  done  with  the  ordinaiy  hypodermic  syringe,  to  which 
Otis's  cocaine-tube  (Fig.  621)  is  attached.  For  searching  the  anterior 
four  fifths  of  the  urethra,  it  is  not  necessary  to  carry  the  point  more 
than  one  inch  beyond  the  meatus,  wlien  the  syringe  is  emj)tied  and 
the  patient  directed  to  grasp  the  glans  and  retain  the  injection  after 
tlie  tube  is  removed.  When  the  membranous  portion  and  neck  of  the 
bladder  are  to  be  examined,  the  cocaine-tube  should  be  carried  just 
beyond  the  cut-off  muscle,  and  about  fifteen  minims  of  the  solution 
thrown  in  here.  In  five  minutes  local  ansesthesia  is  obtained.  A  bulb  of 
medium  size  is  selected  and  properly  warmed  and  oiled.  The  wire  is  not 
curved  in  exploration  of  the  uretha  anterior  to  the  membranous  portion. 
The  penis  should  be  held  at  about  a  right  angle  to  the  plane  of  the  body, 
and,  as  the  instrument  is  being  introduced,  the  organ  should  be  elon- 
gated in  order  to  obliterate  any  folds  in  the  mucous  membrane.  This 
membrane  is  not  so  closely  attached  to  the  connective  tissue  of  the  cor- 
pus spongiosum  but  that  it  can  be  perceptibly  displaced  up  and  down 
and  doubled  upon  itself  if  sufficient  force  is  applied.  If  no  stricture  of 
caliber  smaller  than  the  bulb  is  encountered,  it  will  glide  smoothly  and 
uninterruptedly  down  to  a  point  about  five  inches  from  the  meatus,  where 
it  will  be  arrested,  having  reached  the  end  of  the  bulbous  portion  and 


Fig.  621. — Otis's  cocaine-tube  for  the  urethra, 


lodged  in  a  pocket  just  in  front  of  the  anterior  layer  of  the  triangular 
ligament.  Withdrawing  the  instrument,  it  will  in  all  probability  return 
as  smoothly  as  it  entered.  If,  however,  a  stricture  exists,  and  the  bulb 
used  is  about  the  size  of  the  lumen  of  the  stricture,  as  it  is  carried  into 
the  urethra  a  slight  resistance  will  be  felt.  As  the  instrument  is  with- 
drawn, the  broad  shoulder  of  the  oval  will  come  in  contact  with  the  ob- 
struction, where  it  will  be  arrested.  The  penis  should  now  be  allowed 
to  retract,  and  the  thumb  and  finger  of  the  left  hand  slipped  down  to 
the  level  of  the  meatus,  where  the  wire  is  grasped  and  slightly  bent. 
The  instrument  is  steadily  drawn  through  the  stricture,  and,  as  soon  as 
the  resistance  ceases,  the  wire  is  again  bent  at  the  level  of  the  meatus. 
The  distance  between  the  two  points  at  which  the  wire  is  bent  represents 
the  extent  of  the  stricture. 

When  it  becomes  necessary  to  search  the  urethra  beyond  the  bulb- 
ous portion,  the  wire  should  be  bent  to  correspond  to  the  normal 
curve  of  the  deep  urethra.  The  handle  of  the  instrument  should  be 
bent  in  an  opposite  direction  in  order  to  prevent  the  possibility  of 
getting  the  point  of  the  bougie  turned  toward  the  perineeum.  It  is 
introduced  in  the  same  way  as  the  catheter  or  steel  sound.  When  the 
triangular  ligament  and  compressor-urethrse  muscle  are  encountered, 
by  depressing  the  handle  toward  the  thighs  of  the  patient,  the  bulb  is 


STRICTURE  OF   THE  MALE  URETHRA.  691 

made  to  rise  out  of  the  pocket  in  front  of  the  anterior  layer  of  the 
ligament  and  to  pass  into  the  membranous  portion.  If  a  stricture  is 
present  the  resistance,  if  not  felt  as  the  bulb  goes  through,  will  cer- 
tainly be  appreciated  as  it  is  withdrawn,  if  the  instrument  is  large 
enough.  If  the  patient  is  not  narcotized,  spasmodic  contraction  of  the 
compressor  muscle  may  arrest  the  bulb,  and,  in  a  certain  sense,  simu- 
late stricture. 

In  the  resistance  of  the  muscle  there  is  a  roundness,  smoothness,  and 
elasticity  which  differs  from  the  rough  surface  of  cicatricial  tissue  and 
the  inelastic  grip  of  a  stricture.  When  the  obstruction  is  felt,  the  same 
method  of  measurement  and  location  is  to  be  observed.  A  stricture  may 
be  roughly  estimated  by  the  inti'oduction  of  a  catheter,  ordinary  bougie, 
or  steel  sound,  but  it  can  not  be  intelligently  or  satisfactorily  defined 
without  the  oval  bulbs. 

Not  infrequently  it  will  be  found  that  the  meatus  is  too  naiTOw  to 
admit  a  bulb  of  sufficient  size  to  define  the  stricture,  necessitating  divis- 
ion of  the  meatus  {meatomy).  This  operation  may  be  done  -nith  an 
ordinary  scalpel  or  bistoury,  but  Avith  nothing  like  the  exactness  and 
freedom  from  pain  which  is  secured  when  the  urethrotome  is  employed. 
The  incision  should  be  made  in  the  median  line,  and  should  correspond 
to  the  floor  of  the  urethra.  It  should  not  extend  deep  enough  to  wound 
the  artery  of  the  fraenum,  nor  should  it  be  any  deeper  than  is  sufiicient 
to  admit  the  larger  bougies. 

If  the  bistoury  is  employed,  the  operator  grasps  the  gians  between 
the  thumb  and  finger  of  the  left  hand,  introduces  the  knife,  cutting-edge 
downward,  a  distance  of  a  half-inch,  and  cuts  carefully  outward.  The 
injection  of  cocaine  solution  into  the  tissues  of  the  part  incised  will 
render  the  operation  perfectly  painless.  The  urethrotome  of  Dr.  E.  A. 
Banks,  in  addition  to  its  usefulness  in  dividing  deeper  strictures,  is 
especially  serviceable  in  performing  meatomy.  It  consists  of  a  handle, 
shaft,  and  a  series  of  bulbs.  The  shaft  is  graduated  and  hollow,  and 
has  extending  through  it  a  rod  connecting  with  the  blade.  The  bulbs 
are  of  various  sizes,  are  fenestrated,  and  are  screwed  on  to  the  tip 
in  such  a  way  that  the  window  falls  directly  over  the  blade  which  is 
to  be  projected  through  it.  Upon  the  handle  is  a  sliding-knob  for 
sheathing  or  projecting  the  knife,  and,  at  the  end,  a  screw  gauge  which 
sets  the  blade  for  cutting  to  any  desired  depth  (Fig.  622). 

I 


Fig.  622.— Dr.  E.  A.  Banks's  urethrotome,    a,  Screw-gauge.     6,  Sliding-knob.     <;,  Bulb,    d,  Knife. 

The  operation  is  performed  as  follows  :  A  bulb  is  selected  which  wiU 
fit  the  meatus  fairly  tight,  and  screwed  on  to  the  shaft.  The  gauge 
should  next  be  set  to  aUow  the  knife  to  cut  one  eighth  of  an  inch  in 
depth.  The  blade  is  now  concealed,  the  bulb  oiled  and  introduced 
until  the  knife,  pointing  directly  to  the  middle  line  of  the  floor,  is  half 
an  inch  from  the  meatus.     While  the  glans  is  held  tightly  between  the 


692  A  TEXT-BOOK   ON  SURGERY. 

thumb  and  fiager  of  the  left  hand,  the  blade  is  projected  as  far  as  the 
gauge  will  allow,  and  the  instrument  quickly  pulled  out  of  the  urethra. 
Even  when  cocaine  is  not  employed,  this  incision  gives  scarcely 
any  pain.  The  bulbous  bougie  should  now  be  introduced,  and,  if  the 
meatus  is  still  too  narrow,  the  incision  should  be  made  deeper.  When 
in  this  operation — as  will  not  infrequently  happen— the  artery  of  the 
frsenum  is  divided,  the  bleeding  may  be  readily  controlled  by  plugging 
the  meatus,  and  pressing  into  the  line  of  incision  a  small  strip  of  iodo- 
formized  gauze.  The  patient  should  also  be  directed  to  restore  this 
dressing  should  bleeding  occur  after  urination,  when  the  plug  is  re- 
moved or  during  an  erection.  In  order  to  prevent  a  recontraction  of  the 
opening,  it  is  necessary  to  dilate  the  meatus  at  intervals  of  from  two  to 
four  days  for  five  or  six  weeks  after  the  operation. 

In  strictures  of  very  small  caliber,  and  in  long  and  tortuous  strictures, 
the  oval  bulbs  can  not  be  used.  The  extent  of  such  strictures  can  not  be 
made  out  with  accuracy  until,  by  the  use  of  filiform  bougies  and  careful  di- 
latation, the  smaller  searchers  can  be  introduced.  The  method  of  employ- 
ing these  bougies  will  be  given  in  the  treatment  of  stricture  of  the  urethra. 

Treatment. — The  treatment  of  organic  stricture  of  the  urethra  may 
be  by  dimsion  or  dilatation.  In  the  former  operation  the  stricture  is 
incised  from  within  {internal  urethrotomy),  or  from  without  {external 
urethrotomy).  In  the  latter,  the  stricture  is  gradually  dilated  by  the 
introduction  of  bougies  or  sounds.  Dilatation  may  be  continuous  or 
interrupted.  Immediate  dilatation,  or  divulsion  of  a  stricture,  as  com- 
pared to  urethrotomy,  is  an  unscientific  and  lansafe  procedure,  and  is 
rarely,  if  ever,  justifiable.  With  the  urethrotome,  the  contraction  is  di- 
vided with  accuracy  and  precision  ;  with  the  divulsor,  the  force  is  blindly 
applied,  and  the  depth  and  direction  of  the  tear  is  not  safely  within  the 
control  of  the  operator. 

It  is  difficult  to  lay  down  any  rule  for  the  selection  of  the  method  of 
treatment  to  be  followed  in  any  given  stricture.  In  general  it  may  be 
said  that  internal  urethrotomy  is  preferable  in  all  strictures  anterior  to 
the  membranous  portion,  and  some  form  of  dilatation  in  those  situated 
in  this  portion,  or  in  the  rare  cases  behind  it.  The  exceptions  to  this 
rule  will  be  presently  considered. 

The  method  of  interrupted  dilatation  by  the  frequent  introduction  of 
sounds  or  bougies  may  be  successfully  applied  to  narrow  annular  strict- 
ures  of  comparatively  recent  date,  but  division  of  the  stricture  and  sub- 
sequent dilatation  not  only  ofl'ers  the  quickest  and  surest  means  of  relief, 
but  is  much  less  painful  than  dilatation  without  incision.  The  employ- 
ment of  cocaine  in  urethral  surgery  has  removed  two  great  obstacles  to 
the  cutting  operation,  namely — the  patient's  dread  of  pain  on  the  one 
hand,  and  that  of  ether  narcosis  on  the  other. 

Many  strictures  are,  hoAvever,  of  such  small  caliber  that  a  urethro- 
tome can  not  be  introduced,  and  it  becomes  necessary  to  dilate  them  up 
to  a  size  sufficient  to  admit  the  urethrotome,  or  to  divide  the  stricture  by 
cutting  down  iipon  it  through  the  integument,  an  operation  known  as 
external  urethrotomy. 


STRICTURE   OF  THE   MALE   URETHRA.  693 

Internal  Ureflirotomy. — In  performing  this  operation  a  sufficient 
degree  of  ansesthesia  can  be  obtained  by  the  use  of  cocaine  in  the  vast 
majority  of  cases.  When  the  stricture  is  of  small  caliber,  requiring  a 
deep  incision  from  one  to  two  or  more  inches  in  length,  ether  narcosis 
is  advisable. 

Operation. — Having  injected  about  3  ss.  of  4-per-cent  cocaine  into  the 
urethra,  the  stricture  should  be  accurately  located,  and  its  diameter  and 
extent  determined  by  the  bulbous  -wire  bougies,  as  just  described.  If  it 
is  of  small  caliber,  thus  necessitating  a  deep  incision,  a  greater  degree 
of  insensibility  may  be  required  than  can  be  obtained  by  cocaine  applied 
to  the  mucous  membrane  of  the  urethra.  This  is  readily  obtained  by 
carrying  a  delicate  hypodermic  needle  into  the  tissues  in  the  line  of  in- 
cision, and  injecting  from  twenty  to  thirty  minims  of  a  4-per-cent  solution. 
The  distance  fi-om  the  meatus  to  the  posterior  boundary  of  the  strict- 
ure is  then  measured  on  the  urethrotome,  beginning  at  the  point  where 
the  knife  is  projected,  and  extending  toward  the  handle.  One  fourth 
of  an  inch  should  be  added  to  this  distance  in  order  to  make  it  certain 
that  the  knife  is  carried  well  behind  the  posterior  Kmit  of  the  contrac- 
tion. This  point  on  the  instrument  is  indicated  by  a  small  ring  clipped 
from  the  end  of  a  rubber  tube  and  slipped  over  the  shaft.  It  is  now 
ready  for  introduction. 

In  the  selection  of  a  urethrotome,  the  instrument  of  Otis  will  be  found 
to  fiU  all  the  indications  more  satisfactorily  than  any  other  (Fig.  624).    It 


Fig.  624. — Otis's  dilating'  urethrotome,  with  the  author's  cosr-wheel  attachment. 


consists  of  a  shaft,  handle,  and  blades.  The  shaft  is  composed  of  two 
bars,  which  can  be  separated  or  closed  by  turning  a  screw  at  the  handle, 
where  there  is  arranged  a  dial  which  registers  the  exact  degree  of  dila- 
tation effected  by  the  separation  of  the  bars.  In  the  upper  bar  of  the 
shaft  is  a  slot  or  groove,  along  which  the  knife  is  carried.  When  it 
arrives  near  the  point  of  the  shaft,  the  blade  sinks  into  a  depression 
and  disappears. 

I  have  added  to  this  instrument  a  cog-wheel  apparatus,  attached  near 
the  handle,  by  the  use  of  which  the  knife  is  cai-ried  steadily  forward  or 
backward,  and  is  made  to  cut  with  mathematical  precision. 

The  operator  should  stand  to  the  right  side  of  the  patient,  who  is 
resting  on  the  back,  with  the  legs  fully  extended.  The  knife  should  be 
carried  forward  until  it  disappears  near  the  tip  of  the  urethrotome,  the 
bars  of  which  are  now  closed  and  oiled  as  far  as  it  is  to  be  introduced. 
The  glans  penis  is  grasped  between  the  thumb  and  finger  of  the  left 
hand,  the  organ  held  in  the  same  position  as  when  the  stricture  was 
located,  and  the  instrument  carried  in  until  the  rubber  ring  touches  the 
meatus.     The  left  hand,  releasing  the  penis,  is  made  to  grasp  the  handle 


694  A  TEXT-BOOK   ON  SURGERY. 

of  the  urethrotome  and  steady  it,  while  with  the  right  the  dilating-screw 
is  turned  until  the  arrow  on  the  dial  indicates  a  separation  of  the  bars 
equal  to  the  diameter  of  the  bulb  which  located  the  stricture.  By  turn- 
ing the  cog-wheel  the  knife  is  now  made  to  travel  through  the  more 
superficial  portions  of  the  stricture  from  behind  forward  and  along  the 
median  line  of  the  roof  of  the  urethra.  The  incision  should  commence 
a  quarter  of  an  inch  behind  the  stricture,  always  in  the  roof  of  the  ure- 
thra except  for  meatomy,  and  should  terminate  the  same  distance  in 
front  of  the  anterior  boundary.  Without  changing  the  position  of  the 
urethrotome,  the  knife  is  rapidly  run  back  to  its  original  position,  the 
dilatation  increased  one  size  more,  and  the  knife  again  carried  more 
deeply  through  the  track  of  the  tii'st  incision.  This  manoeuvre  is  re- 
peated untU  the  stricture  is  divided  up  to  Nos.  21  to  23  (U.  S.).  A  wide 
dilatation  with  the  urethrotome  should  be  made  Just  before  it  is  re- 
moved. The  instrument  is  now  withdrawn  after  the  knife  is  concealed 
and  the  blades  half-closed.  If  the  bars  are  brought  closely  together, 
the  mucous  membrane  may  be  caught  between  them.  In  order  to  dem- 
onstrate a  perfect  division  of  all  the  bands,  the  larger  bulbs  should  be 
introduced,  and,  if  these  catch  at  any  point,  a  further  incision  is  re- 
quired. Or  a  full-sized  sound  (Nos.  21  to  23)  may  be  carried  through 
the  stricture,  and  any  undivided  fibers  torn  or  stretched. 

Haemorrhage  after  internal  urethrotomy  is  usually  slight.  When  the 
incision  has  been  made  in  the  j^endulous  part  of  the  urethra,  it  may  be 
readily  arrested  by  turning  the  penis  up  on  the  belly,  laying  a  handful 
of  cotton  or  gauze  over  the  organ,  and  strapping  it  down  with  a  band- 
age carried  around  the  pelvis.  Behind  this  portion,  a  compress  along 
the  perinseum,  or  a  large  gum  bougie  in  the  canal,  will  control  the  bleed- 
ing. The  patient  should  be  put  to  bed  at  once,  and  required  to  remain 
quiet  for  several  days. 

Not  infrequently  within  twenty-four  hours  after  urethrotomy,  or  the 
introduction  of  a  sound  or  other  instrument  into  the  iirethra,  the  patient 
is  seized  with  rigors  or  a  pronounced  chill,  followed  by  a  variable  rise  in 
temperature,  or  the  fever  may  occur  without  any  premonitory  chill. 
When  the  thermometer  registers  100°  F.,  it  is  a  wise  precaution  to  ad- 
minister antipyrin  in  doses  of  from  grs.  x-xx,  and  repeat  this  every 
hour  until  the  decline  in  temperature  is  below  100°.  If  the  pulse  is  cor- 
respondingly increased,  tincture  of  aconite-root  should  be  given  at  the 
same  time. 

The  repeated  introduction  of  steel  sounds  or  gum  bougies  is  essen- 
tial to  the  successful  after-treatment  of  internal  urethrotomy.  If  there 
is  no  marked  febrde  movement,  the  dilatation  should  be  commenced  on 
the  second  or  third  day  after  the  operation.  If  fever  exists,  the  use  of 
the  sounds  should  be  postponed.  Cocaine  should  be  employed,  for,  as 
a  rule,  the  introduction  of  the  sound  is  more  painful  than  the  incision. 
The  urethra  should  be  stretched  to  the  full  size  of  the  sound  introduced 
after  the  cutting.  It  is  well  to  begin  with  No.  17,  and  follow  this  with 
Nos.  19,  20,  and  21,  or  higher,  if  the  urethra  is  unusually  capacious. 
This  should  be  repeated  every  second  or  third  day  for  a  period  of  about 


STRICTUKE   OF   THE  MALE   URETHRA.  695 

three  weeks,  every  fourtli  or  fiftli  day  for  the  same  period  of  time,  then 
once  a  week  for  thi-ee  weeks,  and  twice  a  month  for  three  or  four  months. 
It  is  essential  to  keep  the  walls  of  the  incision  apart  nntil  they  are  lined 
with  new-formed  epithelia. 

If  cystitis,  epididymitis,  or  orchitis  ensue  after  urethrotomy,  all 
operative  measures  should  be  discontinued  until  these  symptoms  disap- 
pear. 

The  prognosis  after  iirethrotomy  should  be  guarded.  Many  cases 
do  not  recur,  but  a  stricture  of  long  standing,  with  extensive  induration, 
no  matter  how  thoroughly  divided  and  carefully  treated,  tends  to  recur. 
It  thus  becomes  necessary  to  employ  dilatation,  either  with  a  sound  in 
the  hands  of  the  surgeon,  or  a  soft  bougie  if  this  duty  is  intrusted  to 
the  patient,  at  intervals  of  every  two  or  three  months,  and  in  some  in- 
stances of tener,  during  the  life  of  the  individual.  That  the  milder  forms 
of  annular  stricture  may  be  permanently  cured  by  judicioixs  treatment 
is  satisfactorily  established. 

In  a  certain  proportion  of  cases  the  stricture  will  be  found  so  close  or 
tigM  that  the  ixrethrotome  can  not  be  passed  through  it,  and  before  the 
division  can  be  effected  it  is  necessary  to  dilate  the  constriction  until 
this  instrument  can  be  introduced.  In  accomplishing  this  purpose  two 
excellent  methods  are  at  the  disposal  of  the  surgeon,  by  either  of  which, 
if  patiently  and  skillfully  utilized,  the  necessity  of  external  urethrotomy 
may  be  obviated  in  all  but  a  very  limited  class  of  cases.  The  methods 
are,  in  order  of  excellence,  (1)  immediate  dilatation  with  Banks's  dilating 
filiform  bougies,  and  (2)  continuous  dilatation  by  inserting  and  leaving 
in  the  urethra  one  or  more  whalebone  filiform s,  or  a  larger  gum  bougie. 
Of  the  procedures  of  Dr.  E.  A.  Banks  and  Sir  Henry  Thompson,  the 
former  is  by  far  the  most  satisfactory.  Its  adoption  has  left  only  a  small 
proportion  of  strictures  for  continuous  dilatation. 

The  dilating  filiform  bougie  (Fig.  625)  is  thus  employed  :  The  urethra 
is  elongated  by  pulling  upon  the  glans,  and  a  smaU  syringef  ul  of  sweet- 


FiG.  625. — Banks's  dilating  filiform  bougies. 

oil  is  thrown  into  the  canal.  The  filiform  is  introduced,  and,  when  any 
resistance  is  encountered,  it  is  slightly  vdthdrawn  and  again  pushed  in. 
By  this  manoeuvre  the  small  tip  of  the  instrument  may  be  insinuated 
through  even  a  long  and  tortuous  tight  stricture.  Once  engaged  in  the 
opening,  it  should  be  carefully  pushed  down  until  it  is  felt  in  the  grasp 
of  the  constriction,  and  then  forced  steadily  through  until  the  full  dilat- 
ing capacity  of  the  largest  part  of  the  bougie  has  traveled  through  the 
stricture.  A  larger  size  should  be  at  once  introduced,  or  the  urethro- 
tome may  be  carried  through  the  opening. 


696  A  TEXT-BOOK   ON   SURGERY. 

This  bougie  may  be  employed  with  perfect  safety.  When  fully  in- 
troduced, the  filiform  iDortion  passes  into  the  bladder,  and,  if  this  organ 
is  empty,  it  curls  upon  itself  from  the  resistance  of  the  vesical  wall.  It 
is  especially  adapted  to  close  strictures  of  the  deep  perineal  and  mem- 
branous urethra. 

If,  after  careful  trial,  it  is  impossible  to  get  the  filiform  into  the 
opening,  the  patient  should  be  put  to  bed  and  given  the  benefit  of  a 
full  dose  of  quinia  and  morphia.  If  the  urine  can  not  be  passed,  supra- 
pubic aspiration  is  indicated.  After  from  twelve  to  twenty-four  hours 
it  will  usually  be  discovered  that  the  filiform  will  slip  readily  into  the 
bladder.  As  soon  as  the  dilatation  is  sufficient  to  admit  the  urethrotome, 
the  operation  of  internal  urethrotomy  should  be  performed. 


2C!^3= 


i.gf^ 


Fio.  626. — Gum  filiform  bougies. 

In  continuous  dilatation,  the  filiform  bougie  (Figs.  626,  627),  or  a 
small  gum  bougie,  is  insinuated  through  the  stricture  and  tied  in  position 
in  the  urethra  by  fixing  a  narrow  strip  of  adhesive  plaster  around  the 
prepuce  behind  the  corona  glandis, 
and  attaching  from  this  to  the  end 
of   the    bougie    three    or  four  silk 
threads  (Fig.  628). 


\ 


G.TI^MANN  1  CD 


Fig.  627. — Whalebone  filiform  bougies.  Fio.  628. — Bougie  tied  in  for  continuous  dilatation. 

The  walls  of  the  stricture  break  down  under  the  constant  pressure  of 
the  whalebone  or  elastic  instrument,  and  it  will  be  found  that  a  bougie, 
with  difficulty  introduced  and  tightly  held  by  the  stricture  soon  after  it 
is  carried  through,  will,  within  twenty-four  hours,  become  loose  and 
easily  movable,  and  a  larger  instrument  will  readily  pass  into  the  same 
opening.  As  soon  as  the  dilatation  has  proceeded  to  the  required  ex- 
tent, the  urethrotome  should  be  employed  and  a  division  effected. 

Strictures  of  the  Membranous  Urethra. — Strictures  of  the  deep  ure- 
thra are  amenable  to  treatment  by  modified  internal  urethrotomy  and  by 
external  urethrotoviy  or  perineal  section. 

The  former  method  consists  in  the  rapid  dilatation  of  the  stricture 
with  the  dilating  filiform  bougie  until  the  Otis  urethrotome  can  be  intro- 
duced. The  straight  instrument  shown  in  Fig.  624  can  be  readily  em- 
ployed in  this  portion  of  the  urethra.  It  is  carried  into  the  stricture 
until  the  knife  is  at  its  jDosterior  limit,  when,  without  separating  the 
bars  of  the  urethrotome — that  is,  without  dilatation — the  blade  is  care- 


STRICTURE   OF  THE  MALE  URETHRA.  697 

fully  drawn  along  the  roof  of  the  urethra,  making  a  shallow  incision  in 
the  wall  of  the  stricture.  It  should  now  be  concealed,  and  the  dilating 
power  of  the  urethrotome  employed.  These  shallow  incisions  may  be 
made  on  the  lateral  aspects  of  the  canal  as  well  as  along  its  roof.  By 
this  operation  the  stricture  is  nicked  and  then  dilated.  If  the  incision 
were  made  when  the  bars  of  the  urethrotome  had  put  the  stricture  on 
the  stretch,  the  large  vessels  of  this  part  of  the  urethra  would  be  en- 
dangered. The  steel  sounds  should  be  used  as  advised  after  internal 
urethrotomy  in  the  anterior  portion  of  the  canal. 

External  urethrotomy^  or  'perineal  section,  is  an  operation  for  the 
relief  of  close  organic  stricture  of  the  bulbous  or  membranous  portions 
of  the  ui-ethra  which  can  not  be  reached  through  the  urethra.  With  the 
exception  of  those  cases  where  urinary  fistula  or  chronic  abscess  exists 
as  a  result  of  stricture,  the  conditions  which  justify  this  operation  are 
rare. 

It  is  performed  with  or  without  a  guide.  When  a  sound  or  bougie 
can  be  carried  through  the  obstruction  into  the  bladder,  the  procedi^re 
is  much  simplified.  Without  this  guide  the  operation  is  surrounded 
with  considerable  difficulty.  In  external  urethrotomy,  the  patient  is 
placed  in  the  lithotomy  iDosition,  being  prepared  as  for  this  operation. 
After  the  anaesthesia  is  complete,  a  careful  and  final  effort  should  be 
made  to  carry  a  filiform  or  soft  bougie  through  the  stricture  and  into 
the  bladder.  If  this  can  not  be  done,  a  good-sized  sound  shoiild  be  car- 
ried down  to  the  obstruction,  and  this  will  serve  to  guide  the  operator 
to  the  commencement  of  the  stricture. 

An  incision  is  then  made  exactly  in  the  median  line,  the  anterior  limit 
being  slightly  in  front  of  the  ascertained  commencement  of  the  stricture, 
the  posterior  extending  toward  the  anus  a  sufficient  distance.  In  making 
this  incision  the  scrotum  should  be  held  up  by  an  assistant,  who  is  di- 
rected not  to  displace  the  median  raphe  to  either  side.  The  legs  must 
also  be  held  in  the  same  relative  position. 

The  bleeding  is  usually  considerable,  as  the  vascular  tissue  of  the 
bulb  is  divided.  All  vessels  should  be  secured ;  but  the  oozing,  which 
is  general,  need  not  retard  the  operation.  As  soon  as  the  sound  or  fili- 
form, at  the  anterior  margin  of  the  constriction,  is  seen,  the  division 
should  continue  along  the  guide  until  the  healthy  urethra  is  reached  be- 
yond the  stricture.  If  no  guide  has  been  introduced,  the  dissection 
should  be  carried  back  in  the  known  direction  of  the  base  of  the  blad- 
der, guided  by  the  location  of  the  prostate  with  the  finger  introduced 
into  the  rectum.  The  first  indication  that  the  canal  is  reached  behind 
the  stricture  will  be  a  gush  of  urine.  On  account  of  the  obstruction, 
the  urethra  between  it  and  the  bladder  is  widely  dilated,  and  for  this 
reason  is  more  readily  found.  It  is  essential  to  the  success  of  this  oper- 
ation that  all  cicatricial  tissue  be  dissected  out.  A  large-sized  steel 
sound  should  now  be  introduced  through  the  meatus  and  into  the  blad- 
der. If  any  difficulty  is  met  with  in  introducing  this  instrument,  a 
flexible  bougie  may  be  substituted.  It  is  not  advisable  to  leave  the 
instrument  in  the  urethra.      In  order  to  prevent  bleeding,  the  wound 


698 


A  TEXT-BOOK   ON  SURGERY. 


should  be  packed  temporarily  with  sublimate  gauze,  held  in  position  by 
a  T-bandage.  A  fatal  hgemorrhage  occurred  in  one  of  the  author's  cases, 
the  packing  having  become  loose  while  the  patient  slept. 

The  urine  usually  escapes  through  the  wound  for  the  first  few  days, 
and  afterward  partly  through  the  wound  and  urethra.  In  rare  instances 
it  escapes  uninterruptedly  through  the  urethra.  The  after-treatment 
consists  in  the  introduction  of  the  sounds  or  bougies  (as  above  directed) 
through  the  urethra  as  far  as  the  neck  of  the  bladder.  This  opera- 
tion should  be  repeated  every  three  or  four  days  until  the  urine  ceases 
to  escape  through  the  wound,  and  once  a  week  thereafter  for  several 
months. 

Interrupted  Dilatation.— In  the  treatment  of  stricture  of  the  urethra 
by  this  method,  there  are  required  steel  sounds  send,  flexible  bougies. 
Steel  sounds  are  of  two  patterns,  the  straight  and  curved.  The  former 
are  preferable  for  dilating  strictures  anterior  to  the  membranous  portion, 
while  beyond  this  point  the  curved  instruments  are  necessary.  The  most 
satisfactory  instruments  are  those  constructed  upon  the  United  States 
scale,*  which  commences  with  the  smallest  steel  instrument,  -g%  of  an 


my^S    5      I       r>      (V       1        H         <>         10  11  12  IS  li  ts  i6  E 

-  cccc  cc :0  000:DO 

U.S.  Scale   -  Unit  '/so  Inch   Diameter. 


inch  in  diameter,  and  increases  ^^  o^  ^^  '^^^^  iii  diameter  for  each  suc- 
cessive sound  to  No.  25  inclusive,  equal  to  |f  of  an  inch.  Nos.  1  to  8, 
inclusive,  are  filiform  and  elastic  bougies. 

A  straight  sound  should  be  six  inches  in  length  clear  of  the  handle, 
slightly  conical  from  the  tip,  back  for  a  distance  of  one  and  a  half  inch. 
This  conicity  should  increase  one  size  for  every  half-inch  for  this  distance. 
Thus,  a  sound  which  measures  No.  17  at  the  tip  increases  to  No.  18  one 
half  inch  back,  to  No.  19  at  one  inch,  and  is  No.  20  at  one  and  a  half 
inch  from  the  poiat,  and  continues  this  size  for  the  entire  shaft. 

A  curved  sound  should  be  nine  inches  long  clear  of  the  handle.  The 
curve  should  involve  only  the  last  two  inches.  The  conicity  extends 
also  one  and  a  half  inch  from  the  tip,  increasing  one  size  for  every  half- 
inch  until  the  full  size  is  reached  at  one  and  a  half  inch  from  the  point. 

*  The  unit  of  the  Frencli  scale  is  one  third  of  a  millimetre  (about  -fj  of  an  inch),  and  each 
size  up  to  No.  30,  inclusive,  increases  one  third  of  a  millimetre  in  diameter.  Divide  any  given 
number  of  this  scale  by  three,  subtract  the  quotient,  and  the  remainder  approximates  the  cor- 
responding size  on  the  above  scale.  Thus,  No.  30,  French,  divided  by  8  =  10;  30  —  10  =  20 ; 
or.  No.  30,  French  =  No.  20,  U.  S. 


STRICTUKE   OF  THE  MALE   URETHRA. 


699 


Thus,  an  instrument  the  shaft  of  which  measures  'No.  20,  is  17  at  the  tip, 
18  at  one  half  inch,  and  19  at  one  inch  farther  back. 


Fig.  630. — Curved  and  straiglit  conical  sounds. 


The  curve  should  be  made  to  correspond  to  that  of  the  normal  deep 
urethra,  which  is  that  of  a  circle  with  a  diameter  of  three  and  a  quarter 
inches ;  "and  the  proper  length  of  arc  of  such  a  circle  to  represent  the 
sub-pubic  curve  is  that  subtended  by  a  chord  two  and  three  quarters 
inches  long"  *  (Fig.  631). 


\5'7a- 


j    3    1<^ 


Flexible  bougies  are  of  various  sizes,  being  conical  for  two  or  three 
inches,  and  olive-pointed  (Figs.  632-635).  They  are  exceedingly  use- 
ful instruments,  and,  when  warmed  before  introduction,  are  incapable 
of  injury  to  the  urethra,  even  when  an  unusual  degree  of  force  is  em- 


*  Van  Buren. 


700 


A  TEXT-BOOK   ON   SURGERY. 


ployed.     The  black  French  bougie  is  preferable.     The  filiform  instru- 
ment has  already  been  described. 

In  dilating  a  stricture  with  the  conical  steel  sound,  the  method  of  in- 
troduction is  identical  with  that  given  in  using  the  metal  catheter.  In 
the  interrupted  dilata- 
tion a  mild  degree  of 
force  is  exercised,  and 
the  seance  is  repeated 
on  every  second,  third, 
or  fourth  day.  The 
length  of  the  interval 
between  the  introduc- 
tions must  be  deter- 
mined by  the  symp- 
toms in  each  case,  the 
object  being  to  accom- 
plish moderate  divul- 
sion  at  each  sitting  with- 
out producing  marked  inflammation.  The  sound  should  never  be  carried 
beyond  the  point  where  its  full  dilating  power  is  applied  to  the  strict- 
ure. In  this  way  irritation  of  the  prostatic  urethra  and  neck  of  the 
bladder  may  be  avoid^d  in  all  save  the  deepest  variety  of  strictures. 

The  dUatation  of  strictures  by  the  use  of  conical  steel  sounds  should 
be  limited  to  those  cases  in  which  the  stricture  is  of  sufficient  caliber 
to  admit  at  least  ISTo.  15,  U.  S.,  and  is  narrow  or  linear  in  character, 
so  that  it  may  be  made  to  give  way  without  the  employment  of  too 
great  force.  The  smaller  sounds  are  capable  of  penetrating  the  walls  of 
the  urethra  unless  they  are  used  with  great  skill  and  carefulness,  while 
the  larger  instruments  will  not,  within  the  limit  of  safety,  succeed  in 
the  dilatation  or  rupture  of  a  broad  or  tortuous  stricture.  Incision  with 
the  urethrotome  is  a  safer  and  less  painful  operation,  and  the  sounds 
serve  an  admirable  purpose  in  the  after-treatment. 

In  using  the  soft  bougies  in  the  anterior  portion  of  the  urethra,  they 
may  be  passed  in  straight ;  but,  when  the  deeper  portion  is  invaded, 
they  should  be  curved  as  much  as  possible,  to  correspond  to  the  sub- 
pubic curve  of  this  canal. 

Foreign  Bodies  in  the  UrefJira. — Calculi  occasionally  lodge  in  the 
urethra,  and  substances  introduced  through  the  meatus — as  fragments 
of  a  catheter,  etc. — may  require  removal  by  the  surgeon.  The  diagnosis 
will  be  evident  from  the  symptoms  of  obstruction  to  the  escape  of  urine, 
by  recognition  of  the  body  by  digital  pressure  along  the  canal,  and  by 
exijloration  through  the  meatus.  Stone  may  be  made  out  by  the  grating 
sound  which  is  emitted,  or  by  the  sense  of  friction  upon  a  rough  and 
hard  surface  which  is  conveyed  to  the  fingers  along  the  sound.  A  me- 
tallic substance  may  also  be  recognized  by  the  peculiar  click  which  is 
elicited  when  it  is  brought  in  contact  with  the  exploring  instrument. 

Removal  may  be  effected  through  the  meatus,  or  by  incision  directly 
through  the  floor  of  the  urethra  at  the  point  of  lodgment.     It  is  always 


FOREIGN  BODIES  IN  THE  URETHRA. 


701 


desirable  to  avoid  incision  throiigli  the  nrethral  wall  when,  by  the  use  of 
forceps  or  any  mechanism,  the  extraction  can  be  eflfected  by  the  meatus 
without  doing  too  great  violence  to  this  canal.     If  the  substance  is  nar- 


FiG.  636. — Straight  and  curved  aEigator-jawed  urethral  forceps. 

row  and  smooth,  it  may  be  seized  with  the  forceps  (Figs.  636,  637)  and  ex- 
tracted. The  straight  alligator-forceps,  or  the  instrument  of  Hale,  is 
preferable  for  the  anterior  portion  of  the  iirethra,  whUe  for  the  deeper 


Fig,  637. — Hale's  instrument  for  removing  foreign  bodies  from  the  urethra.    (After  Linhart.) 

part  the  curved  instrument  is  more  suitable.     For  a  round  body,  the 
scoop  or  curette  will  prove  more  satisfactory  (Fig.  638). 

In  using  the  forceps,  the  instrument-closed  should  be  carried  down 
until  its  beak  strikes  the  foreign  substance,  when  the  jaws  should  be 
slowly  separated  and  pushed  farther  in,  so  that  they  may  pass  between 
the  lining  membrane  of  the  urethra  and  the  body.  They  should  then 
be  firmly  closed  and  cautiously  moved  a  slight  distance  to  and  fro  in 

order  to  determine  whether  the  mu- 
cous membrane  has  been  caught  in 


Fig.  638. — Curette,  or  scoop,  for  the  re- 
moval of  calculus  in  the  urethra. 
(After  Van  Buren  and  Keyes.) 


Fig.  639. — Calculi  removed  from 
the  urethra.  (The  author's 
case.) 


the  instrument.  This  danger  will  in  great  part  be  obviated  if,  just  at 
the  moment  when  the  jaws  are  applied  to  the  foreign  substance,  the 
urethra  is  put  upon  the  stretch  by  pulling  upon  and  elongating  the 
penis.  The  canal  should  be  lubricated  by  an  injection  of  sweet-oil.  If 
stricture  exists,  urethrotomy  may  be  necessary  before  the  substance  can 


702 


A  TEXT-BOOK   ON  SURGERY. 


be  extracted.  In  a  case  which  came  under  my  care,  two  strictures  were 
divided  with  the  urethrotome.  From  behind  the  first  constriction  two 
calculi  were  removed,  and  several  after  the  second  stricture  was  divided 
(Fig.  639).  In  this  operation  a  scoop  proved  more  serviceable  than  the 
forceps. 

In  a  second  operation  I  found  it  necessary  to  perform  external  ure- 
throtomy, cutting  directly  down  upon  the  calculi  (two  in  number),  which 
were  easily  removed  through  the  incision.  The  direct  injection  of  cocaine 
into  the  tissues  secured  complete  aneesthesia.  The  wound  should  be  left 
to  close  as  in  the  ordinary  operation  of  perineal  urethrotomy. 

Urinary  Fistula  communicating  toitit  the  Urethra. — In  congenital 
or  acquired  urinary  fistula  communicating  with  the  urethra  the  following 
operative  measures  are  indicated :  When  the  fistula  opens  in  the  peri- 
nseum  or  lower  surface  of  the  penile  urethra,  the  method  of  Szymanow- 
ski  offers  the  surest  prospect  of  success.  It  is  essential  that  all  inflam- 
mation in  and  about  the  field  of  operation  be  allayed,  sinuses  slit  up  and 
healed,  and  all  strictures  divided,  or  stretched  and  cured.  The  bowels 
should  be  well  emptied  for  two  or  three  days  before  the  operation.  For 
perineal  fistula  the  lithotomy  position  is  preferable  ;  the  parts  should  be 
shaved  and  disinfected.  Proceed  as  follows :  Let  the  dark  spot  at  F 
(Fig.  640)  represent  the  opening  of  the  fistula.  A  straight  incision  A  B 
is  made,  passing  along  one  edge  of  the  fistula,  extending  three  quarters 
of  an  inch  each  way  from  the  opening.  This  incision  passes  through  the 
skin  and  superficial  fascia.     The  edge  of   this  incision  is  raised,  and, 


D  Ci 


dissecting  away  from  the  fistula,  the  skin  is  lifted  to  form  a  pocket,  the 
bottom  of  which  is  the  dotted  curved  line  AG B  (Fig.  640),  and  the 
lifted  edge  or  entrance  to  this  pocket  the  straight  incision  A  F  B. 
On  the  opposite  side,  corresponding  accurately  Math  the  attached  bot- 
tom of  the  pocket  A  G  B.,  •&  curved  incision  A  D  B  (Fig.  640)  is  made, 
the  greatest  depth  of  the  flap  being  from  three  quarters  to  one  inch 
(McBurney).*  From  this  flap,  with  a  pair  of  small  scissors  curved  on 
the  flat,  remove  the  ei^idermis,  except  over  an  area  amply  sufficient  to 


*  "  New  York  Medical  Journal,"  November  6,  1886,  p.  514  ct  seq. 


URINARY  FISTULA.  'j'OS 

cover  the  fistulous  opening.  (This  area  is  represented  in  white  between 
i^andi),  in  Fig.  640  a.) 

The  flap  A  D  B  (Fig.  640  a)  is  now  dissected  up,  taking  with  it  a 
generous  allowance  of  subcutaneous  fat  and  fascia,  down  to  about  an 
eighth  of  an  inch  of  the  original  straight  incision  A  F  B,  this  attach- 
ment being  left  to  give  it  a  sufficient  blood-supply.  As  this  A  D  B  is 
turned  over  toward  (7,  it  hinges  on  the  attached  edge  A,  F  B,  and,  as  it 
is  slipped  beneath  the  pocket  A  G  B  F,  it  will  be  seen  that  the  unde- 
nuded  (white)  portion  suffices  to  form  the  new  floor  of  the  urethra.  It 
being  ascertained  that  the  flap  fits  accurately,  it  is  brought  out  again 
and  a  series  of  five  or  six  loops  of  fine  catgut  sutures  are  inserted  by 
carrying  the  needle  through  the  skin  one  eighth  inch  from  the  curved 
dotted  line  A  O  B  into  the  bottom  of  the  pocket,  and  beneath  the  integ- 
ument, directly  opposite  and  through  the  free  edge  of  the  flap  ABB, 
and  back  again,  being  brought  out  finally  one  quarter  inch  from  the 
point  of  entrance  A  C  B  (Fig.  640  b).  As  these  sutures  are  tied,  the 
flap  is  inverted  and  secured.  It  now  remains  to  close  the  open  wound 
by  sutui'es  of  fine  silk,  which  snugly  approximate  the  lines  A  B  and 
ABB  (Fig.  640  b).  The  result  is  shown  in  A  D  B  (Fig.  640  c).  It 
is  important  to  keep  the  bowels  from  moving  and  the  patient  quiet  with 
morphia  for  several  days.  Every  three  or  six  hours  the  soft  Nelaton 
catheter  should  be  inserted,  the  urine  drawn  ofl',  and  the  bladder  washed 
out  with  four  or  five  ounces  of  warm  boracic-acid  solution,  gr.  x-  §  j.  On 
withdrawing  the  catheter  the  end  should  be  closed  in  order  to  prevent 
the  escape  of  even  a  few  drops  of  its  contents  in  the  urethra.  The  silk 
sutures  should  be  removed  about  the  seventli  day,  and  the  use  of  the 
catheter  discontinued  only  when  the  wound  is  thoroughly  united.  In 
rare  instances  the  floor  of  the  jDrostatic  and  posterior  part  of  the  mem- 
branous portion  of  the  urethra  may  be  destroyed,  and  the  fistula  open 
directly  into  the  rectum. 

The  following  case  which  came  under  my  care  will  serve  to  illustrate 
this  form  of  fistula :  * 

The  patient,  twenty-seven  years  of  age,  merchant,  came  under  my 
care  in  August,  1887.  He  came  of  healthy  stock,  and  had  had  no  sickness 
of  a  serious  character  until  1883,  when  symptoms  of  vesical  calculus 
supervened,  for  which  a  left  lateral  lithotomy  was  done  in  August,  1886. 
The  stone  removed  was  reported  to  be  the  size  of  a  hen's  egg. 

A  urethro-perineal  fistula  remained  after  this  operation,  and  from 
August,  1886,  to  August,  1887,  four  attempts  were  made  to  close  this 
opening,  without  success.  In  the  last  of  these  operations,  a  drainage- 
tube,  about  one  and  one  half  inch  in  length,  was  inserted  in  the  perineal 
opening,  and  left  with  the  deep  end  in  the  urethra.  This  tube,  about 
three  sixteenths  of  an  inch  in  diameter,  was  lost  sight  of,  the  surgeon 
and  patient  supposing  it  had  escaped  externally  and  had  been  thrown 
away  with  the  dressings.  The  last  operation, was  followed  by  consider- 
able pain,  which  was  persistent.      In  the  course  of  three  months  an 

*  Read  before  the  Ontario  Medical  Association,  at  Toronto,  June,  1888. 


704 


A  TEXT-BOOK   ON  SURGERY. 


Fig.  641. — Calculus  formed 
on  a  piece  of  driinai'e- 
tube  as  a  nucleus.  (Act- 
ual size.) 


abscess  opened  into  the  rectum  through  the  anterior  wall,  and  the  urine 
began  to  flow  freely  in  this  new  channel.  About  this  time  the  perineal 
opening  closed  and  an  abscess  formed  in  each  tunica  vaginalis.  These 
were  incised,  and  when  I  first  saw  the  patient  were  entirely  healed.  At 
this  date  (August,  1887)  nearly  all  the  urine  passed  through  the  rec- 
tum. The  patient  suffered  greatly,  and  had  to  be  kept  constantly  under 
the  influence  of  opium. 

An  examination  per  rectum  revealed  the  presence  of  a  stone,  the  end 
of  which  was  on  a  level  with  the  anterior  surface  of  the  rectum,  about 
one  inch  beyond  the  anal  aperture.     The  opening 
was   slightly  dilated,   and   the  stone  was  removed 
through  the  rectum  by  means  of   strong  forceps. 
It  had  formed  in  and  upon  the  drainage-tube,  and 
is  seen  in  natural  size  in  Fig.  641.     After  consulta- 
tion with  Dr.  Edward  L.  Keyes,  it  was  determined  to 
prepare  the  patient  for  operation,  which  was  done, 
and  on  September  13,  1887,  I  operated  as  follows : 
The  patient,  in  ether  narcosis,  was  placed  in  the  Sims  position,  and 
a  large  Sims  vaginal  speculum  was  introduced.     The  opening  through 
the  anterior  wall  of  the  rectum  measured  three  fourths  of  an  inch  in 
length,  with  an  irregular  width  of  from  one  eighth  to  one  fourth  of  an 
inch.     It  led  directly  into  the  urethra  near  the  junction  of  the  membra- 
nous and  prostatic  JDortions.     The  floor  of  the  urethra  was  entirely  de- 
stroyed.     The  right  edge  (patient's  right)  of 
the   opening  was   seen   to   be   undermined,   as 
shown  by  the  dotted  surface  B  (Fig.  642). 

I  determined  to  attempt  the  formation  of  a 
new  floor  to  the  urethra  by  turning  the  mucous 
membrane  of  the  rectum  into  this  position. 
The  operation  performed  was  a  modification  of 
the  method  of  Szymanowski.  Two  crescentic 
incisions  were  made,  as  shown  at  J.  J.  (Fig. 
642),  being  about  parallel  with  the  edges  of  the 
opening,  but  approaching  more  closely  at  its 
upper  and  lower  angles.  These  incisions  went 
deep  into  the  wall  of  the  rectum  and  included 
the  mucous  and  muscular  layers.  The  two  lat- 
eral flaps  were  dissected  up,  the  left  to  within 
an  eighth  of  an  inch  of  the  edge  of  the  opening ; 
the  right  could  not  be  carried  so  far  on  account 
of  the  pocket  which  undermined  this  side. 

The  flaps  were  now  turned  toward  each  oth- 
er and  their  raw  edges  made  to  meet  in  the 
middle  line,  while  the  raw  surfaces  looked  into 
the  rectum,  and  the  mucous  surfaces  into  the  urethra  (Fig.  643).  Sut- 
ures of  silk-worm  gut  were  inserted,  as  shown  at  B  (Fig.  643).  These 
sutures  were  about  three  sixteenths  of  an  inch  apart,  and  were  so  in- 
serted that  they  did  not  penetrate  to  the  cavity  of  the  urethra.     On 


Fig.  642. — Showing  the  anterior 
wall  of  the  rectum,  and  open- 
ing into  it  at  E,  a  sinus  from 
the  membranous  and  prostatic 
urethra.  B.  Cul-de-sac,  which 
undermined  the  right  margin 
of  the  opening.  A  A^  Line  of 
incision,  along  which  the  flaps 
were  dissected  as  far  inward  as 
C.  For  their  nutrition  the  two 
lateral  flaps  depended  upon  the 
limit  between  the  dotted  line 
C  and  the  margins  of  the  open- 
ing E.    i>,  The  perinajum. 


URINARY  FISTULA. 


705 


Fio.  643.  —  Schematic.  Transverse  section 
through  the  urethra  and  rectum,  showing 
the  method  by  which  the  flaps  were  turued 
from  the  mucous  membrane  of  the  rectum 
to  make  the  floor  of  the  urethra,  a,  Ure- 
thra, b.  The  right  flap  dissected  from  b'. 
c,  The  lert  flap  from  c'.  d,  The  silk-worm 
gut  suture  in  position  (not  entering  the  cav- 
ity of  the  urethra. 


account  of  the  thinness  of  the  flap  at  one  point,  I  was  compelled  to 
pass  one  suture  into  the  urethra. 

A  Nelaton  catheter  was  carried  through  the  meatus  and  urethra  into 
the  bladder,  and  through  this  the  urine  ran  out  at  inter^'als.  When- 
ever the  urine  accumulated  enough  to 

create  a  desire  to  expel  it,  about  six  ,.-- — -%, 

ounces  of  Thiersch's  solution  were 
thrown  in  to  dilute  it ;  and  when  this, 
with  the  normal  contents  of  the  blad- 
der, were  evacuated,  the  same  quan- 
tity was  thrown  in  again  and  imme- 
diately expelled.  In  this  way  the 
wound  was  keiDt  practically  free  from 
ii'ritation  by  the  urine.  Divulsion  of 
the  sphincter  ani  removed  all  danger 
or  annoyance  from  spasm  of  this  or- 
gan. The  bowels  were  kept  quiet  for 
nine  days,  and  liquid  diet  was  en- 
forced. The  patient  had  been  placed 
on  liquid  diet  for  ten  days  prior  to  the 
operation. 

The  sutures  were  left  in  situ.  The 
wound  healed  promptly,  and  the  patient  left  for  his  home  in  three 
weeks  after  the  operation.  In  April,  1888,  seven  months  later,  he  re- 
turned, complaining  of  slight  irritation  in  the  rectum,  and  said  he 
thought,  at  rare  intervals,  a  few  drops  of  water  escaped  into  the  bowel. 
On  examination,  three  of  the  sutures  were  still  in  position,  but  no  open- 
ing could,  by  most  careful  search,  be  discovered.  The  sutures  were  re- 
moved, and  in  a  few  days  the  patient  was  discharged. 

Congenital  Malformations  of  the  Urethra. — In  exstrophy  of  the  blad- 
der the  urethra  is  absent,  and,  in  certain  rare  anomalies,  it  may  open  into 
the  groin,  upon  the  side  of  the  glans  penis,  in  the  median  line  of  the 
dorsum  penis  (epispadias),  in  the  median  line  below  at  any  point  on  the 
corpus  spongiosum  (hypospadias). 

Hypospadias  is  the  most  common  of  the  congenital  deformities  of  the 
urethra.  "VV^hen  the  opening  is  within  one  inch  of  the  normal  position 
of  the  meatus,  operative  interference  for  the  purpose  of  establishing  a 
new  urethral' canal  is  not  indicated.  It  will,  however,  in  many  instances 
be  found  necessary  to  enlarge  the  abnormal  opening  in  order  to  permit 
the  free  escape  of  urine.  When  the  false  meatus  is  so  far  back  that  in 
sexual  intercourse  the  semen  can  not  be  ejaculated  into  the  vagina,  a 
plastic  operation  may  be  undertaken.  The  chances  of  failure  are  always 
so  great  that  it  is  scarcely  ever  Justifiable  to  undertake  this  operation  in 
the  effort  to  establish  an  artificial  channel  for  the  urine,  for,  even  when 
the  opening  is  as  far  back  as  the  perineeum,  soiling  may  be  prevented 
by  urinating  in  the  squatting  posture.  When,  on  account  of  absence  of 
the  corpus  spongiosum  (the  corpora  cavernosa  being  well  developed), 
painful  bowing  occurs  during  erections,  oijeration  may  be  advised. 
45 


V06 


A  TEXT-BOOK   ON   SURGERY. 


The  operation  for  the  relief  of  hypospadias  consists  in  introducing 
a  long,  delicate  knife  at  the  apex  of  the  glans,  and  carrying  it  directly 
back  along  the  normal  position  of  the  corpus  spongiosum  until  it  emerges 
in  the  anterior  limit  of  the  urethra  at  the  abnormal  opening.  This  arti- 
ficial channel  should  be  large  enough  to  admit  a  straight  catheter,  which 
is  now  introduced  through  it  and  well  into  the  urethra  beyond  the  hy- 
pospadias. 

In  closing  the  abnormal  meatus  the  operation  of  Szymanowski  just 
given  should  be  made.  Interrupted  dilatation  with  the  straight  steel 
sounds  should  be  made  every  three  or  four  days  for  several  months 
after  the  catheter  is  removed. 

Neoplasms. — Papillomata  and  fibromata  are  occasionally  met  with 
growing  from  the  mucous  membrane  of  the  urethra.  They  produce 
symptoms  of  obstruction  varying  with  their  shape,  size,  and  point  of 
attachment.  When  situated  near  the  meatus,  they  may  be  observed  by 
means  of  the  urethral  speculum  (Pig.  644).     When  deeply  located,  the 


Fig.  644. — Urethral  speculum  of  H.  Marion-Sims. 

obstruction  may  be  recognized  by  the  bulbous  bougie.  The  only  treat- 
ment is  removal,  which  may  be  done  by  the  wire  snare  or  by  torsion 
with  forceps.  In  extreme  cases,  a  longitudinal  incision  may  be  required 
in  the  median  line  of  the  floor  of  the  penis  in  order  to  effect  removal. 

Cancer  may  originate  in  this  canal,  or  more  frequently  extend  here 
from  malignant  disease  of  the  prepuce  and  glans.  Tuberculosis  also 
occasionally  attacks  the  urethra. 

The  Penis. — The  congenital  malformations  of  the  urethra  just  given 
may  be  included  with  deformities  of  the  penis.  The  corpus  spongiosum 
is  at  times  arrested  in  development,  while  the  corpora  cavernosa  are  fully 
formed,  causing  the  organ  to  bow  when  an  erection  occurs.  One  cavern- 
ous body  is,  in  rare  instances,  not  fully  formed,  and,  when  an  erection 
takes  place,  the  curve  is  lateral,  with  the  concavity  toward  the  affected 
side.  The  penis  is  occasionally  double,  with  separate  urethrse.  In  her- 
maphrodites it  is  rudimentary. 

Inflammation  of  this  organ  is  rare,  except  as  a  result  of  traumatism. 
It  occasionally  becomes  involved  by  the  extension  of  a  phlegmonous  or 
erysipelatous  process  from  the  scrotum  or  abdomen,  or  from  urethritis 
and  posthitis.  The  organ  becomes  greatly  swollen,  and  a  painful  con- 
dition of  chordee  is  almost  constant.  Retention  of  urine  may  occur,  as 
well  as  suppuration  or  gangrene. 

In  the  treatment  of  mild  inflammation  of  this  organ,  local  applica- 
tions will  usually  prove  sufficient.  The  tendency  to  erection  should  be 
controlled  by  the  use  of  opium  or  chloral  and  potassium  bromide  in  full 


THE  PENIS. 


707 


doses.     When  gangrene  is  threatened,  free  incisions  in  the  long  axis  of 
the  organ  should  be  practiced. 

Wounds  of  the  penis,  involving  more  than  the  integument,  always 
bleed  profusely.  Haemorrhage  may  be  controlled  by  dii-ect  compression 
with  a  roller,  or  by  throwing  a  few  turns  of  an  elastic  ligature  around  this 
organ  near  the  pubic  junction.  When  the  urethra  is  divided  in  whole  or 
in  part,  it  is  best  to  stitch  the  separated  walls  together  by  close  sutures 
of  delicate  silk.  Catgut,  though  more  desirable  in  one  sense,  is  too 
readily  absorbed  to  hold  the  edges  of  the  wound  in  contact  for  a  length 
of  time  sufficient  to  secure  union.  It  is  not  usually  necessary  to  insert 
a  catheter,  and  it  is  best  to  dispense  with  this  on  account  of  the  irrita- 
tion it  causes.  Any  tendency  to  stricture  may  be  treated  later.  When 
the  dense  capsule  of  the  corpus  cavernosum  is  divided,  this  should  be 
included  in  the  sutures  which  are  carried  through  the  wound  in  the  in- 
tegument. A  guarded  prognosis  should  be  made  in  all  deep  injuries  of 
the  penis.  Distortion  during  erection,  and  stricture,  are  frequent  results 
of  such  lesions. 

Fracture  of  the  corpora  cavernosa,  an  accident  which  occurs  in  rare 
instances  as  a  result  of  great  violence  to  the  erected  organ,  is  a  ditiicult 
injury  to  treat.     Deformity,  with  more  or  less  loss  of  function,  is  apt  to 
ensue.     The  organ  should  be  laid  up  on  the  abdomen,  and  kept  in  a 
condition  of  as  perfect  quiet  as  possible.     Cold  apijlications  arc  indi- 
cated, and,   in  case  of 
strangulation  from  ef- 
fusion of  blood  or  from  '         , 
any    other   cause,    free 
longitudinal      incisions 
may  be  necessitated. 

Carcinoma. — Epithe- 
lioma of  the  penis  is  not 
an  uncommon  affection. 
It  commences  as  a  small 
pimple  or  erosion  on 
the  mucous  surface  of 
the  prepuce  or  on  the 
glans,  gradually  spread- 
ing untU,  if  left  alone, 
the  entire  organ  is  in- 
volved and  destroyed. 
The  margins  of  the  ulcer 
are  indurated,  elevated, 
sinuous,  and  slightly 
everted.  The  indura- 
tion, as  a  rule,  is  con- 
fined to  the  immediate 
borders  of  the  sore,  not 
extending  into  the  deeper  tissues  unless  inflammation  supervenes.  As 
the  disease  progresses,  the  center  of  the  surface  becomes  studded  with 


Fio.  645. — Carcinoma  of  the 


lenis.      (From  a  case  in  Momit  Sinai 
lospital.j 


708  A  TEXT-BOOK   ON   SURGERY. 

buds  of  newly  formed  cells  and  capillaries,  giving  it  an  appearance  not 
unlike  a  cauliflower  (Fig.  645).  Ulceration  occurs  at  various  portions  of 
the  mass,  and  a  dirty  quality  of  pus  is  exuded.  The  odor  from  the  de- 
composing tissues  is  peculiarly  penetrating  and  offensive. 

Within  a  period  of  time,  varying  from  two  to  six  or  eight  months,  ' 
enlargement  of  the  inguinal  glands  is  observed.     This  enlargement  may 
be  inflammatory  or  metastatic.     As  a  rule,  metastasis  is  not  rapid  in 
epithelioma  of  the  penis,  and  induration  of  the  glands  does  not,  on  this 
account,  preclude  the  hope  of  cure  after  amputation. 

The  principal  cause  of  epithelioma  of  the  penis  is  prolonged  irrita- 
tion of  the  glans  and  prei^uce  from  retained  secretions.  All  the  cases 
which  have  come  under  my  observation  have  occurred  iu  jjatients  with 
unusually  long  and  tight  prepuces.*  It  is  usually  met  with  ia  the  mid- 
dle-aged and  old,  although  it  sometimes  occurs  in  early  adiilt  life. 

The  diagnosis  of  epithelioma  is  not  very  difiicult  after  ulceration 
takes  place.  The  indurated  sinuous  and  everted  borders  of  the  ulcer, 
the  red,  cauliflower-like  appearance  of  the  mass,  and  the  steady  progress 
of  the  disease  in  the  destruction  of  all  the  tissues  in  its  path,  are  symp- 
toms not  met  with  in  any  other  lesion  of  this  organ.  Warty  growths 
(papillomata),  when  not  seen  early  in  theu"  development,  may  at  times 
simulate  epithelioma,  especially  when  these  vegetations  are  luxuriant, 
are  undergoing  ulceration,  are  covered  with  purulent  matter,  and  are 
the  seat  of  repeated  hsemoiThages.  No  matter  how  wide-spread  the  pap- 
illomatous neoplasm  may  be,  at  the  outskirts  of  the  mass  will  be  found 
tufts  or  minute  warts  sufficiently  isolated  to  be  recognized.  In  the  very 
earliest  stages  of  development  of  the  ulcer  of  epithelioma,  it  is  scarcely 
possible  to  make  a  positive  diagnosis  between  it  and  chancroid,  or  even 
a  simj^le  ulcer  of  the  prepuce  and  glans  penis. 

Treatment  and  Prognosis. — The  only  justifiable  treatment  of  epithe- 
lioma of  the  penis  is  an  immediate  excision  of  the  neoplasm  by  ampu- 
tation. The  line  of  ampirtation  should  always  be  wide  of  the  limit  of 
the  disease.  If  the  induration  of  the  ulcer  is  well  defined,  and  is  lim- 
ited closely  to  the  margins  of  the  erosion,  the  amputation  may  be  made 
with  one  inch  of  sound  tissue  intervening.  If  the  inguinal  glands  are 
enlarged,  and  if  the  surgeon  has  reason  to  be  satisfied  that  the  enlarge- 
ment is  due  rather  to  inflammatory  engorgement  than  to  metastasis,  the 
operation  is  still  advisable,  and  the  prognosis  not  altogether  unfavorable. 
When  metastasis  of  the  glands  is  unmistakable,  amputation  may  be 
done  to  rid  the  patient  of  the  foul  and  ulcerating  mass,  although  a  favor- 
able prognosis  can  not  be  entertained.  In  the  earlier  development  of  the 
growth,  where  a  sufficient  extent  of  healthy  tissue  intervenes  between 
the  induration  and  the  line  of  excision,  ampiitation  offers  a  strong  hope 
of  permanent  relief.  In  the  earlier  period  of  development  of  the  ulcer, 
if  doubt  exists  as  to  its  character,  it  is  advisable  to  administer  the 

*  In  an  experience  of  several  years  in  attendance  at  Mount  Sinai  Hospital,  T  have  not  met 
with  a  case  of  epithelioma  of  the  penis  in  an  individual  upon  whom  in  early  life  circumcision 
had  been  performed. 


THE   PENIS.— SIMPLE   AMPUTATION.  709 

iodide  of  potassium,  together  with  protoiodide  of  mercury,  for  a  num- 
ber of  weeks.  In  this  way  the  differentiation  between  the  later  mani- 
festations of  syphilis  and  epithelioma  may  be  assured. 

Operation. — Amputation  of  the  penis  may  be  performed  by  two 
methods :  1,  simple  amputation  ;  2,  amputation  with  transplantation  of 
the  urethra  to  the  peringeum.  In  the  selection  of  the  method,  the  oj)era- 
tor  must  be  guided  by  the  nearness  of  the  disease  to  the  pnbes  and  scro- 
tum. Ordinarily,  when  the  induration  is  limited  to  the  glans,  a  simple 
amputation  may  be  made  at  a  point  about  one  inch  posteiior  to  this. 
If  the  line  of  amputation  must  be  chosen  at  or  nqyj  near  the  level  of 
the  pubes,  the  second  method  will  be  preferable,  for  the  reason  that  re- 
traction of  the  stump  will  always  occur,  and  the  urine  escaping  over  the 
scrotum  will  keep  up  a  constant  and  annoying  excoriation  and  condition 
of  uncleanliness.  In  the  operation  with  transplantation  of  the  urethra, 
the  urine  is  voided  in  the  squatting  posture,  and  escapes  freely  behind 
the  scrotum.* 

.Simple  Amputation. — Having  shaved  and  thoroughly  cleansed  the 
pubes,  scrotum,  and  penis,  throw  an  elastic  ligature  around  the  organ  at 
the  level  of  the  pubes.  If  the  line  of  amputation  is  very  near  the  liga- 
ture, this  may  be  prevented  from  slipping  by  transfixing  the  penis  with 
a  large  needle  just  in  front  of  the  tourniquet.  Seize  the  mass  with  a 
double  hook,  and,  holding  it  steady,  with  a  long,  thin-bladed  knife  cut 
the  organ  smoothly  off  at  a  point  at  least  one  inch  behind  the  disease. 
A  tenaculum  should  be  in  readiness  to  prevent  the  erectile  tissue  from 
retracting.  The  tube  of  the  urethra  should  now  be  dissected  ujd  for  half 
an  inch,  and  the  tissues  of  both  cavernous  bodies  again  divided  on  a 
level  with  the  point  to  which  the  dissection  of  the  spongiosum  has  been 
carried.  The  urethra  is  now  split  by  passing  the  knife  through  its  roof 
and  floor,  and  a  silk  suture  carried  through  the  end  of  each  lateral  half. 
A  thread  is  also  passed  through  the  dense  capsule  of  the  corpora  caver- 
nosa to  prevent  their  retraction  when  the  elastic  ligature  is  removed. 
All  vessels  which  may  be  recognized  before  loosening  the  rubber  band 
should  now  be  secured  with  catgut  ligatures,  and  the  remaining  bleed- 
ing points  caught  up  as  the  tourniquet  is  gradually  loosened.  The  su- 
tures passed  through  each  half  of  the  urethra  are  now  carried  through 
the  edge  of  the  incision  in  the  skin  to  which  it  is  sewed.  A  simple 
dressing  completes  the  operation. 

Humphreijs  Operation. — The  elastic  ligature  is  carried  around  the 
penis  close  up  to  the  level  of  the  pubes,  as  in  the  preceding  operation, 
and  the  organ  severed  as  near  the  ligature  as  possible.  The  vessels  in 
the  corpora  cavernosa  should  be  tied  at  once.  An  incision  should  now 
be  made  through  the  skin  along  the  under  surface  of  the  corpus  spon- 
giosum, back  to  and  splitting  through  the  base  of  the  scrotum,  so  as  to 
expose  the  tube  of  the  urethra  for  about  two  and  a  half  inches.     This 

*  I  have  performed  tbis,  the  operation  of  Humphrey,  three  times,  and  in  none  of  these 
patients  has  any  unpleasant  symptom  followed.  Two  of  the  cases  are  still  under  observation 
three  years  after  the  operation. 


no 


A  TEXT-BOOK   ON  SURGERY. 


tube  is  carefully  dissected  out  from  its  attachment  beneath  and  be- 
tween the  two  corpora  cavernosa  for  this  distance,  and  is  turned  down 
on  to  the  perinseum  through  the  slit  in  the  posterior  wall  of  the  scrotum. 
The  urethra  should  next  be  split  along  the  median  line  of  its  roof  for  a 

distance  of  half  an 
inch  back  from  the 
end,  and  the  edges 
stitched  to  the  mar- 
gins of  the  wound  in 
the  integument  of  the 
perinseum.  The  oper- 
ation is  completed  by 
closing  the  jDOsterior 
slit  through  the  scro- 
tum, and  stitching  the 
margin  of  the  wound 
in  the  skin  of  the  an- 
terior wall  of  the  scro- 
tum to  that  of  the 
belly  at  the  root  of 
the  penis,  so  as  to 
cover  in  and  include 
the  stump  of  the  am- 
putated corpora  cav- 
ernosa. The  appear- 
ance of  the  parts  aft- 
er this  operation  is 
shown  in  Fig.  646. 

Sarcoma  of  the  pe- 
nis is  exceedingly  rare. 
It  may  be  recognized 
by  its  rapid  development,  the  absence  of  glandular  enlargement,  the  gen- 
eral invasion  of  the  cavernous  bodies — in  certain  cases  producing  a  con- 
tinuous and  painful  erection  of  the  organ — and  by  its  resemblance  to  the 
well-known  appearance  and  behavior  of  sarcomatous  tumors  in  other 
portions  of  the  body.  The  treatment  should  consist  in  immediate  am- 
putation. 

Phimosis,  or  inability  to  retract  the  prepuce  behind  the  corona  glan- 
dis,  is  a  frequent  condition  of  childhood,  and  occasionally  met  with  in 
adult  life.  It  is  both  a  congenital  and  an  acquii'ed  affection,  and  may  be 
partial  or  complete.  The  prepuce  may  be  adherent  to  the  glans,  or 
phimosis  may  exist  without  adhesions,  the  opening  in  the  foreskin 
being  so  narrow  that  retraction  is  impossible.  A  prepuce  ordinarily 
retractile  may  become  irretractible  as  a  result  of  any  inflammatory  pro- 
cess of  the  glans  and  foreskin.  This  condition  is  not  infrequently  met 
with  in  gonorrhoea  and  with  chancroid. 

Congenital  phimosis  is  an  imfortunate  affection,  preventing  perfect 
cleanliness  by  retention  and  decomposition  of  the  retained  secretions 


-Humphrey's  operation.     (From  a  ease  of  the  author's,  at 
Mount  Sinai  Hospital.) 


THE    PEXIS— PHIMOSIS. 


'11 


and  Tmne.  and  indncing  a  condition  of  irritation  wMch  it  were  better  to 
avoid  by  timely  operative  interference.  Inflammatory  or  acquired  pM- 
mosis  always  requires  careful  attention,  and  very  frequently  a  surgical 
operation,  to  prevent  gangrene  or  to  expose  a  subpreputial  chancroid. 

The  operative  measures  may  include :  1,  amputation  of  the  prepuce 
(circumcision  1 :  2.  dilatation  of  the  preputial  orifice  with  forced  retrac- 
tion :  3,  incision  of  the  anterior  portion  of  the  prepuce  and  retraction. 

The  iirst  of  these  procedures  should  be  preferred  in  all  cases  in  which 
there  is  no  inflammatory  process  present,  while  the  latter  is  advisable  in 
phimosis  with  acute  balano-posthitis. 

Operation. — In  adults,  circumcision  may  be  done  with  perfect  free- 
dom from  pain  by  the  proper  employment  of  cocaine.  In  children  under 
six  years  of  age,  chloroform  narcosis  is  advisable. 

In  adults,  proceed  as  follows :  Cleanse  the  parts  to  be  operated  upon 
with  l-to-oOCH)  sublimate  solution,  and  throw  an  elastic  ligature  around 
the  penis  at  the  level  of  the  pubis.  From  tU  xx-xxx  of  a  4-per-cent 
cocaine  solution  are  now  injected  by  inserting  the  needle  at  the  margins 
of  the  preputial  orifice,  and  carrying  it  back  between  the  mucous  mem- 
brane and  integument  of  the  prepuce  a  little  behind  the  proposed  line 
of  section.  In  the  middle  of  the  dorsum  three  or  fouj  minims  are  forced 
out  of  the  syringe,  the  needle  partially  withdrawn  and  carried  a  haK- 
inch  to  right  and  left  of  this  point,  and  a  like  quantity  is  injected,  and 
so  on  until  the  entire  line  of  amputation  is  anaesthetized.  As  a  rtile.  it 
will  suiBee  to  insert  the  needle  once  in  the  median  line  above,  and  once 
at  the  frsenum.  and  from  these  two  locations  it  may  be  thrust  beneath 
the  skin  to  either  side  until  the  prepuce  is  completely  encircled. 

In  selecting  the  line  of  incision,  the  best  rule  is  to  allow  the  parts  to 
assume  their  normal  relations,  and  mark  the  foreskin,  by  repeated 
punctures  with  the  scalpel,  parallel  with  and  one  fourth  of  an  inch  an- 
terior to  the  outline  of  the  corona  of  the  glans.  A  dtill-pointed,  grooved 
director  should  now  be  passed  between  the  upper  surface  of  the  glans 
and  the  prepuce,  in  the  median  line,  until  the  point  is  at  the  line  of 
amputation.  A  sharp -pointed  bistoury  is  next  slipped  along  the  groove 
in  the  director,  thitist  through,  and  the  foreskin  split  by  cutting  from 


J\  ^1 


behind  forward  (Fig.  647i.  Or  this  incision  may  be  made  from  be- 
fore backward  with  a  pair  of  straight  scissors.  The  edges  of  the  flaps 
are  now  seized  with  a  pair  of  mouse-tooth  fixation-forceps,  and  trimmed 


712 


A  TEXT-BOOK   ON  SURGERY. 


Fig.  649.— (After  Malgaigne.) 


off   with  scissors,    being  careful  to  follow  the  line  already  indicated 
(Fig.  648). 

When  these  incisions  are  completed,  it  will  be  observed  that  the  edge 
of  the  divided  mucous  membrane  remains  at  the  level  of  the  incision — 
namely,  a  quarter  of  an  inch  in  front  of  the  outline  of  the  corona  glan- 
dis— while  the  skin  retracts  beyond  the  corona.  The  mucous  membrane 
should  now  be  turned  back,  and  its  edge 
switched  to  that  of  the  incision  in  the  skin. 
I''  ine  catgut  should  be  used,  and  an  interrupt- 
( I L  or  continuous  suture  employed.  The  for- 
mer is  somewhat  more  accurate,  although  it 
1  quires  much  more  time  in  its  insertion  than 
I  lie  latter.  It  is  important,  in  the  effort  to 
■^1  cure  immediate  union,  that  at  all  points  the 
approximation  is  carefully  made  between  the 
margins  of  the  integument  and  mucous  mem- 
brane. After  the  sutures  are  inserted,  the 
mucous  membrane  rolls  back,  leaving  the  stitches  behind  the  corona 
(Fig.  649).  The  elastic  ligature  is  now 
removed,  and  a  light  dressing  applied 
over  the  line  of  sutures.  This  operation 
is  entirely  bloodless.  The  patient  should 
be  directed  to  prevent  the  urine  from 
getting  into  the  wound.  The  sutures 
disappear  by  absorption,  and  the  union 
is  complete  in  from  four  to  ten  days. 

When  the  prepuce  is  adherent  to  the 
glans,  it  will  be  found  impossible  to  in- 
troduce the  grooved  director  as  above  unless  the  adhesions  are  first 

broken  up.  Under  these 
conditions,  the  following 
operation  should  be  per- 
formed :  Carry  the  phi- 
mosis-forceps  (Fig.  650) 
into  the  ojpening  of  the 
prepuce,  and  allow  the 
blades  to  expand  so  that 
the  hooklets  at  the  tip 
will  catch  in  the  mucous 
membrane.  The  fore- 
skin is  now  drawn  well 
to  the  front  by  an  assist- 
ant, while  the  operator 
slips  the  thumb  and  fin- 
ger of  the  left  hand  along 
the  penis  and  grasps  the 
foreskin  just  in  front  of  the  meatus.  In  young  children,  considerable  care 
is  necessary  to  prevent  cutting  off  a  portion  of  the  glans  with  the  pre- 


FiG.  650. — Gil-dner's  phimosis-foreeps. 


ULCERS   OF    THE  PENIS.  713 

puce.  The  foreskin  is  next  amputated  witli  the  scissors  just  in  front  of 
♦■he  finger  and  thumb  (Pig.  651).  As  retraction  takes  place,  it  will  be  seen 
that  the  line  of  section  in  the  skin  is  near  the  corona,  while  that  in  the 
mucous  membrane  is  only  a  little  back  of  the  meatus.  This  should  be 
seized  with  the  mouse-tooth  forceps,  and  the  adhesions  broken  loose  or 
divided  with  the  scissors.  The  mucous  lining  should  now  be  pared  back 
to  a  sufficient  distance,  and,  if  necessary,  a  second  division  of  the  pre- 
puce made.     The  sutures  are  applied  as  in  the  preceding  operation. 

Dilatation  or  divulsion  of  the  prepuce  is  rarely,  if  ever,  indicated. 
It  is  performed  by  introducing  the  point  of  a  small,  closed  dressing- for- 
ceps into  the  opening  of  the  foreskin,  and  stretching  or  tearing  this  by 
forced  separation  of  the  blades.  The  operation  is  completed  by  retract- 
ing the  prepuce  and  breaking  up  all  adhesions.  In  the  after-treatment 
it  is  essential  to  move  the  foreskin  back  and  forth  over  the  gians  once 
or  twice  daily  to  prevent  the  re-formation  of  adhesions. 

Incision  limited  to  the  anterior  half -inch  of  the  foreskin,  and  in  the 
median  line  of  the  dorsum,  is  a  more  advisable  operation  when  circum- 
cision is  contraindicated.     Retraction  should  be  immediately  effected. 

Ulcers  of  the  Penis. — Sores  may  occur  upon  the  integument  of  the 
penis,  usually  near  the  prepuce ;  ixpon  the  mucous  lining  of  the  fore- 
skin ;  the  glans  ;  within  the  meatus ;  and  along  the  urethra.  Venereal 
sores  are  occasionally  met  with  upon  the  integument  of  the  scrotum, 
abdomen,  perinseum,  and  thighs.  Ulcers  of  the  penis  only  will  be  con- 
sidered here.  They  are  divisible  into  two  classes — namely,  the  non- 
specific and  the  specific  ulcer.  To  the  former  belong  the  sores  which 
follow  abrasions  and  the  eruption  of  herpes.  They  are  more  or  less 
phagedenic  in  character,  the  extent  and  rapidity  of  the  process  of  ne- 
crobiosis being  due  to  the  degree  of  virulence  of  the  inoculating  pus- 
corpuscles,  the  thoroughness  of  the  inoculation,  and  the  impoverished 
condition  of  the  tissues  attacked.  The  chancroid  belongs  to  this  group. 
In  the  second  class  belongs  the  specific  ulcer  of  syphilis. 

Non-specific  Ulcers. — A  simple  ulcer  of  the  penis  is  extremely  rare. 
It  may  occur  here,  as  in  other  parts  of  the  body,  as  a  result  of  trauma- 
tism, or  an  inflammatory  process  not  due  to  the  inoculation  of  a  virus. 
Thus,  the  molecular  death  of  a  variable  extent  of  tissue  may  follow  a 
simple  abrasion  if  the  part  involved  is  not  kept  free  from  all  irritation, 
and  if  there  prevails  a  condition  of  impaired  nutrition,  in  which,  as  is 
well  known,  the  tissues  yield  readily  to  the  destructive  process.  Under 
more  healthful  conditions,  an  abrasion  of  the  glans  or  prepuce  under- 
goes the  simple  process  of  repair  seen  in  similar  lesions  of  the  integu- 
ment and  mucous  surfaces  elsewhere.  Abrasions  usually  occur  on  the 
sides  of  the  penis,  close  to  the  attachment  of  the  prepuce,  just  behind 
the  corona  or  near  the  frsenum.  The  glans  is  rarely  involved,  although 
the  meatus,  especially  at  its  lower  angle,  may  be  torn.  Bleeding  suffi- 
cient to  attract  the  attention  of  the  patient  is  rare,  unless  extensive 
laceration  has  occurred. 

The  ulcer  of  herpes  is  usually  situated  upon  the  surface  of  the  mu- 
cous lining  of  the  prepuce,  less  frequently  upon  its  cutaneous  surface. 


714  A  TEXT-BOOK  ON  SURGERY. 

and  the  glans.  It  begins  as  a  vesicular  eruption.  There  may  be  one  or 
many.  Multiple  herpetic  vesicles  may  be  scattered  or  in  clusters,  linear, 
semilunar,  or  circular  in  arrangement.  In  the  recent  state  the  herpetic 
vesicle  is  round  at  its  base,  measuring  from  one  twelfth  to  one  twenty- 
fifth  of  an  inch  in  width.  It  consists  of  a  thin  investing  membrane  rest- 
ing upon  a  slightly  red  and  irritated  base,  and  containing  a  clear,  serous 
fluid,  which  often  escapes  by  rupture  of  the  membrane  before  the  vesicle 
is  observed.  Upon  the  skin  they  rapidly  dry  on  account  of  evaporation 
of  the  fluid  contents,  and  the 'floor  of  the  patch  becomes  covered  over 
with  a  light  incrustation.  Upon  the  mucous  and  moist  surfaces,  in- 
crustation does  not  occur.  The  circumference  of  the  base  exposed  after 
rupture  of  the  vesicle  is  usually  round,  with  well-defined  walls  leading 
perpendicularly  down  to  the  bottom  of  a  shallow  excavation. 

In  typical  cases  of  genital  herpes,  the  morbid  process  ends  here, 
the  sore  healing  without  suppuration.  Not  infrequently,  however,  the 
floor  becomes  covered  with  a  layer  of  pus,  the  walls  are  undermined 
and  break  down,  forming  an  ulcer  which  is  phagedenic  in  character. 
The  character  of  the  pain  varies.  In  some  instances  there  is  a  sting- 
ing, burning,  sensation  felt  in  the  part  affected ;  in  others  there  exists 
total  insensibility. 

Herpes  is  a  neurosis  due  to  a  local  irritation  of  the  nerve  termina- 
tions in  the  part  attacked.  In  some  instances  a  severe  neuralgia  of  the 
branches  of  the  sacral  or  lumbar  plexuses  exists  at  the  time  of  the  erup- 
tion on  the  glans  and  prepuce.  UncleanMness  is  a  frequent  cause  of  this 
disease.  Any  irritation  of  the  glans  or  prepuce  may  induce  it,  and  one 
attack  is  apt  to  be  followed  by  a  second. 

In  mild  and  ordinary  cases  it  runs  its  course  in  from  ten  days  to  two 
or  three  weeks.  In  other  forms,  especially  when  inoculation  occurs,  it 
may  last  for  a  niimber  of  weeks,  and  is  usually  complicated  by  lymphan- 
gitis and  adenitis. 

Phagedenic  ulcer  of  the  genital  organs  was  formerly  held  to  be  the 
result  of  the  inoculation  of  a  specific  poison — the  virus  of  "chancroid"; 
but,  since  ulcers  which  in  appearance  and  behavior  do  not  differ  from 
the  so-called  chancroidal  ulcer  have  been  produced  by  inoculation  with 
corpuscles  taken  from  the  pustules  of  acne,  from  gonorrhoeal  pus,  etc., 
the  specific  nature  of  this  virus  can  not  be  maintained.  Even  the  spe- 
cific ulcer  of  syphilis  vnll,  as  a  result  of  repeated  and  prolonged  irrita- 
tion, take  on  a  phagedenic  character. 

This  ulcer  results  most  frequently  from  direct  contagion,  the  pus-cor- 
puscles which  contain  the  virus  being  lodged  in  an  abrasion  of  the  in- 
tegument, prepuce,  or  glans  The  period  of  incubation — that  is,  the 
length  of  time  between  the  date  of  the  contact  and  the  recognition  of 
the  sore — will  vary  in  different  individuals.  It  has  been  seen  within 
twenty-four  hours,  and,  in  rare  instances-  as  much  as  twenty  days  have 
elapsed.  In  a  very  lai'ge  majority  of  cases  the  inflammation  is  observed 
within  the  first  nine  days  after  the  inoculation.  The  rapidity  of  its  ap- 
pearance depends  in  part  upon  the  quantity  and  virulence  of  the  pus, 
but  chiefly  upon  the  thoroughness  with  which  it  is  brought  into  con- 


ULCERS   OF   THE   PEXIS.  715 

tart  witli  tlie  tissues  in  an  abrasion.  The  spread  of  the  nicer  and  its 
phagedenic  character  also  depend  uj)on  the  virulence  of  the  poison  and 
the  condition  of  the  tissues  at  the  time  of  the  invasion.  The  ulcer  is 
usually  located  on  the  side  of  the  jDenis,  just  behind  the  corona  giandis 
at  the  preputial  attachment,  at  the  points  -where  abrasions  are  most 
frequent.  It  may  be  on  the  cutaneous  surface  of  the  prepuce,  upon 
the  body  of  the  penis,  the  scrotum,  or  within  the  meatus.  There  may 
be  one  or  more,  owing  to  the  number  of  abrasions  and  the  distribu- 
tion of  the  virus.  A  single  ulcer  may  result  from  the  confluence  of  sev- 
eral contiguous  points  of  inocalation.  It  is  iirst  noticed  as  a  light  red- 
ness or  flush,  usually  circular  or  elliptical  in  shape,  or,  if  the  abrasion 
is  irregular  in  outline,  it  will  conform  to  this.  Within  a  few  hours  after 
the  appearance  of  the  redness,  its  center  becomes  elevated  and  a  pustule 
is  formed,  which  soon  breaks  down,  discharging  a  small  quantity  of 
matter. 

If  the  sore  is  not  seen  early,  the  pustule  may  escape  observation. 
When  the  inoculation  occurs  upon  a  surface  denuded  of  its  mucous  mem- 
brane or  epidermis,  a  pustule  is  not  formed.  The  walls  of  a  phage- 
denic ulcer  are  usually  precipitous.  At  times  the  superficial  layers  of 
the  skin  resist  disintegration  longer  than  the  deeper  layers  and  subcu- 
taneous tissues,  giving  the  edges  an  undermined  appearance.  It  tends 
to  spread  in  width  rather  than  in  depth,  although  in  a  certain  propor- 
tion of  cases  extensive  destruction  of  tissue  may  occur  in  all  directions. 
The  floor  of  the  ulcer  is  covered  Avith  pus  and  broken-down  tissues  in 
various  stages  of  decomposition.  A  small  quantity  of  matter  of  creamy 
consistence  may  be  removed  with  a  pellet  of  cotton.  A  membrane  or 
film  of  a  yellowish-brown  color  usually  adheres  to  the  floor  with  con- 
siderable tenacity. 

A  zone  of  redness  extends  along  the  edges  of  the  ulcer  in  advance  of 
the  tissue-destruction.  In  many  ulcers  this  is  not  more  than  a  line  in 
width.  If  the  sore  is  subjected  to  irritation,  the  inflammatory  redness 
and  induration  may  spread  widely  into  the  surrounding  tissues. 

Pain,  which  is  always  present,  varies,  as  a  rule,  with  the  extent  of 
the  inflammatory  process. 

In  a  typical  phagedenic  ulcer  of  the  penis,  lymphangitis  and  adenitis 
of  the  inguinal  glands  are  always  present  in  a  varying  degree.  In  the  sim- 
pler fonns,  adenitis  does  not  occur,  although  the  lymphatic  channels  in 
the  neighborhood  of  the  soi-e  may  be  involved.  Inguinal  bubo  is  always 
a  painful  complication.  It  may  be  lateral  or  bilateral.  If  the  sore  is  in 
the  median  line,  or  if  there  are  ulcers  on  both  sides,  both  groups  of 
glands  wiU  be  affected.  Suppuration  of  the  inguinal  bubo  of  phagedenic 
ulcer  is  not  uncommon.  The  violence  of  the  inflammatory  process  here 
is  subject  to  the  same  conditions  as  given  for  the  primary  ulcer.  One 
or  more  glands  may  be  involved  and  suppurate.  In  severe  adenitis,  the 
inflammation  extends  to  the  tissues  immediately  surrounding  the  glands. 
The  mass  appears  as  one  large  swelling,  over  which  the  integument  is 
red  and  oedematous,  and  to  which  it  is  adherent.  Phagedenic  bubo  is 
apt  to  follow  a  virulent  phagedenic  ulcer  of  the  penis. 


fjlQ  A  TEXT-BOOK   ON  SURGERY. 

Treatment.— Simple  nicer  of  the  penis,  if  left  without  interference, 
nsually  heals  within  a  few  weeks ;  the  ulcer  of  herpes  is  usually  more 
obstinate.  The  process  of  repair  may  be  greatly  facilitated  by  a  careful 
removal  of  all  sources  of  irritation.  Strict  cleanliness  is  essential,  no 
matter  what  form  the  ulcer  may  assume.  Soaking  the  part  in  warm 
black  wash  (calomel  3  j  to  lime-water  Oj)  two  or  three  times  a  day  is  an 
excellent  method  of  treatment.  The  local  use  of  liquor  plumbi  subaceta- 
tis  dilutum  is  also  advisable. 

In  addition  to  the  foregoing,  it  is  essential  to  keep  the  sore  uncov- 
ered by  the  prepuce,  which  should  be  worn  back  behind  the  corona. 
Circumcision  may  at  times  become  necessary  to  obtain  a  permanent  cure. 
If  the  simpler  remedies  Just  given  do  not  succeed,  the  local  use  of  the 
nitrate-of-silver  pencU  is  indicated. 

In  phagedenic  ulcer,  as  a  rule,  more  vigorous  measures  are  necessary. 
The  severity  in  local  treatment  will  depend,  however,  upon  the  rapidity 
of  molecular  death  which  the  poison  is  causing  in  the  tissues.  If  its 
progress  is  slow,  and  the  inflammation  mild  in  character,  recovery  may 
be  brought  about  by  the  treatment  laid  down  for  simple  and  herpetic 
ulcer.  If  within  the  first  few  days  of  its  appearance  the  spread  of  the 
sore  is  rapid,  or  if,  when  first  brought  to  the  notice  of  the  physician,  it 
is  more  than  a  quarter  of  an  inch  in  diameter,  and  the  zone  of  redness 
spreads  well  out  into  the  tissues,  it  should  be  treated  as  follows  :  By  the 
introduction  of  a  delic'ate  hypodermic  needle  through  the  sound  tissues, 
after  which  its  point  should  be  carried  under  the  base  of  the  ulcer,  from 
fifteen  to  twenty  minims  of  a  4-per-cent  solution  of  cocaine  should  be 
injected,  by  which  means  complete  anaesthesia  may  be  secured.  The 
pus  should  now  be  removed  from  the  bottom  of  the  sore  with  a  pellet 
of  absorbent  cotton  on  the  end  of  a  small  piece  of  wood.  The  parts  im- 
mediately about  the  ulcer  should  be  coated  over  with  vaseline  or  oil, 
to  protect  them  from  excoriation.  A  small  quantity  of  carbonate  of 
soda  should  be  on  hand  to  neutralize  any  excess  of  acid.  In  applying 
pure  nitric  acid,  the  ulcer  should,  if  possible,  be  held  so  that  it  will  con- 
tain the  acid  without  letting  it  run  over  the  edges.  It  is  best  applied 
by  means  of  a  wooden  match  or  tooth-pick  dipped  in  the  acid,  and  the 
point  immediately  carried  into  the  floor  of  the  ulcer.  It  should  be  con- 
veyed into  every  portion  of  the  sore,  and  allowed  to  remain  in  contact 
with  the  virus  for  one  or  two  minutes.  The  excess  may  now  be  soaked 
out  with  the  cotton  pellets,  and  the  ulcer  filled  with  soda.  A  piece  of 
lint  moistened  in  vaseline  will  serve  as  ^  dressing.  When  nitric  acid  can 
not  be  had,  the  actual  cautery  should  be  employed. 

Iodoform  may  be  dispensed  with,  on  account  of  the  disagreeable  odor 
of  this  substance. 

When  phagedenic  ulcer  occurs  beneath  an  irretractible  prepuce,  this 
should  be  incised  and  the  sore  treated  as  above.  Ulcer  of  the  meatus 
should  also  be  burned  with  nitric  acid.  Complete  rest  is  essential,  and 
constitutional  measures  looking  to  the  improved  nutrition  of  the  tissues 
are  strongly  indicated.  If  suppuration  occurs  in  the  glands  of  the  in- 
guinal region,  free  incision  should  be  made  and  free  drainage  estab- 


ULCERS   OF   THE  PENIS— SYPHILIS.  717 

lished.     Phagedenic  bubo  should  be  treated  in  the  same  manner  as  the 
phagedenic  ulcer. 

TTie  Specific  Ulcer  (Chancre)— S^/jyMUs.—^j^ihilis  is  a  disease 
afPecting  in  a  varying  degree  the  nutrition  of  all  the  tissues  of  the 
human  body.  It  is  caused  by  the  introduction  into  the  blood  of  a 
specific  virus.  In  practice,  two  distinct  forms  are  met  with,  namely, 
the  acquired  and  the  inJieritecl. 

Acquired  syphilis  ensues  when  the  specific  virus  is  carried  into  the 
lymph  or  blood-channels  of  a  human  being  not  syphilitic  at  the  time 
of  inoculation.  Although  no  demonstration  of  a  specific  germ  of  this 
disease  is  as  yet  widely  accepted,  the  '■'■bacilli^''  discovered  by  Dr.  Sig- 
mund  Lustgarten  in  the  primary,  secondary,  and  tertiary  lesions  of 
syphilis,  if  not  the  carriers  of  this  virus,  are  clearly  in  intimate  rela- 
tion with  the  inflammatory  changes  occurring  throughout  the  disease. 

While  it  is  generally  believed  that  an  abrasion  of  the  skin  or  mucous 
surface  is  essential  to  the  absorption  of  the  syphilitic  virus,  it  is  ex- 
tremely probable  that,  if  it  is  brought  and  kept  in  contact  with  the  thin 
unbroken  skin  or  mucous  membranes,  absoi-ption  may  occur.  A  disease 
the  germs  of  which  are  transported  within  the  spermatic  elements,  and 
■with  such  potency  that  the  impregnated  ovum  is  affected,  can,  under 
favorable  conditions,  in  all  probability  be  transmitted  from  unbroken 
cutaneous  or  mucous  surfaces  thi'ough  which  it  is  demonstrable  that 
the  absorption  of  other  elements  occurs. 

The  chief  source  of  the  contagion  is  in  the  fluid  which  transiides  from 
the  surface  of  the  iaitial  lesion  or  ulcer  (chancre),  and,  next  in  order,  that 
from  mucous  patches.  The  blood  of  a  syphilitic  patient  also  carries  the 
poison  and  produces  the  disease  if  injected  into  or  inoculated  upon  the 
tissues  of  another.  The  same  is  true  of  the  matter  or  fluid  from  the 
cutaneous  lesion  of  the  secondary  stage  of  syphilis.  It  is  doubtful  if 
the  lesions  of  tertiary  syphilis  are  capable  of  reproducing  the  disease. 

Saliva  from  a  syphilitic  subject,  unmixed  wdth  the  discharge  from 
mucous  patches,  fails  to  produce  syphilis.  Seminal  fluid  from  a  syphi- 
litic man,  in  any  of  the  stages  of  the  disease,  is  held  to  l^e  not  directly 
contagious.  However,  the  mother  may  acquire  the  disease  from  a  child 
in  utero,  the  child  being  syphilitic  from  the  spermatozoa.  Milk  from  a 
woman  in  any  stage  of  syphilis  will  not  produce  the  disease  if  injected 
into  the  tissues  or  ingested  as  food. 

The  transudation  from  a  fissure  in  the  nipple  of  a  syphilitic  nurse 
wiU,  if  lodged  in  an  abrasion  upon  the  lips,  tongue,  or  buccal  wall  of 
the  child,  produce  the  specific  disease  in  a  non-syphilitic  subject.  On 
the  other  hand,  a  syphilitic  child  may  inoculate  a  healthy  nurse.  The 
urine,  tears,  and  sweat  of  syphilitic  patients  do  not  convey  the  specific 
virus.  Pus  from  a  vaccine  pustule  on  a  syphilitic  subject  does  not  con- 
vey the  virus  of  this  disease  even  when  the  vaccination  is  successful.  If, 
however,  blood  or  the  fluid  from  any  early  syphilitic  lesion  is  mingled 
with  the  pus,  syphilis  results. 

While  the  most  frequent  seat  of  inoculation  is  upon  the  genital  or- 
gans, or  in  their  immediate  vicinity,  it  may  occur  at  any  part  of  the 


718  A  TEXT-BOOK   ON  SURGEKY. 

body.  The  contagion  may  be  direct  or  indirect.  In  the  former,  the 
virus  of  a  specilic  ulcer  is  brought  directly  in  contact  with  an  abrasion 
upon  a  non-syphilitic  subject.  In  the  latter,  the  poison  adheres  to  some 
intermediate  agent,  and  thence  is  conveyed  to  the  abrasion.* 

The  clinical  history  of  a  typical  case  of  acquired  syphilis  left  without 
treatment,  and  in  a  certain  proportion  of  cases  in  which  treatment  is  in- 
stituted, is  divided  by  usage  into  three  stages — primary,  secondary,  and 
tertiary.  In  a  majority  of  cases,  when  properly  managed,  the  later  mani- 
festations may  be  eliminated,  and  the  secondary  stage  made  shorter  and 
less  severe. 

^h.e  primary  stage  includes  :  1,  absorption  of  the  virus  ;  2,  the  ulcer; 
3,  local  lymphangitis  and  adenitis. 

The  symptoms  which  belong  to  the  second  stage  are  the  cutaneous 
eruptions,  mucous  patches,  fever,  arteritis,  condylomata,  alopecia,  iritis, 
and  general  adenitis.  In  the  tertiary  stage,  the  pathological  changes  are 
chiefly  confined  to  the  arteries,  viscera,  bones,  the  integument,  and  the 
subcutaneous  and  submucous  connective  tissues.  This  is  the  period  of 
gummy  tumors,  connective- tissue  formations,  arterial  occlusion,  and  deep 
ulcers  of  the  skin  and  mucous  membranes. 

The  usual  duration  of  the  first  stage  is  from  six  to  nine  weeks.  Sec- 
ondary symptoms  may,  however,  appear  at  the  flfth  or  sixth  week  from 
the  date  of  inoculation.  On  the  other  hand,  in  rare  instances,  they  may 
be  delayed  to  between  the  third  and  sixth  month.  The  limitation  of  the 
stages  of  this  disease  is  in  great  part  arbitrary. 

The  duration  of  the  second  stage  varies  from  the  fifth  or  sixth  week 
(or  in  delayed  cases  the  sixth  month  after  contact)  to  about  the  end  of 
the  first  year  after  the  inoculation. 

The  tertiary  stage  begins  at  the  end  of  the  preceding  stage,  and  may 
last  indefinitely. 

First  Stage. — When  the  specific  virus  is  brought  in  contact  with  a 
broken  cutaneous  or  mucous  surface,  absorj)tion  may  begin  at  once  or 
be  delayed  for  a  considerable  period.  The  abrasion  may  be  so  insignifi- 
cant that  the  patient's  attention  is  not  attracted  to  it,  and,  although  the 
virus  is  lodged  in  it,  it  may  heal  over  within  a  few  days.  If  subjected 
to  irritation  by  friction,  or  the  simultaneous  inoculation  with  the  virus 
of  j)hagedenic  ulcer  or  other  virus,  inflammation  supervenes,  and  an  ulcer 
more  or  less  phagedenic  in  character  appears. 

Absorption  takes  place  chiefly  through  the  lymphatics.  It  may  occur 
through  the  blood-vessels,  and  it  is  possible  that  in  those  cases  in  which 
constitutional  symptoms  appear  with  great  rapidity  and  severity,  the 
dissemination  of  the  virus  takes  place  in  this  way. 

The  rapidity  of  lymphatic  absorption  varies.  There  is  usually  a  pe- 
riod of  about  three  weeks  from  the  time  of  lodgment  of  the  virus  until 

*  In  one  of  my  cnses  the  inoculation  occurred  in  a  fissure  of  tlie  lip  in  the  person  of  a  mer- 
chant who  was  using  a  glass  in  common  with  a  customer  in  sampling  wines.  In  1883  a  patient 
presented  himself  at  the  clinic  who  had  had  a  specific  ulcer  and  syphilis  resulting  from  heing 
tattooed  upon  the  arm.  The  operator  moistened  the  point  of  the  needle  with  saliva  in  which 
the  virus  from  raucous  patches  was  mingled,  and  thus  conveyed  it  into  the  integument. 


SYPHILIS.  719 

the  local  inflammatory  pi'ocess  is  recognized.  That  the  specitic  virus 
has  passed  into  the  neighboring  lymph-channels  before  the  appearance 
of  the  ulcer  (chancre)  seems  satisfactorily  proved  in  the  repeated  ex- 
periment of  freely  excising  the  initial  lesion  at  its  earliest  appearance, 
in  which  cases  constitutional  infection  was  not  retarded  or  prevented. 

The  ulcer  of  syphilis  always  appears  at  the  point  where  absorption 
of  the  virus  took  place.  From  the  inoculation  to  its  appearance,  the 
lapse  of  time  is  iisually  about  three  weeks — not  less  than  ten  days  ;  occa- 
sionally delayed  as  many  weeks.  Its  duration  varies  from  two  to  ten 
weeks,  occasionally  longer.  It  often  begins  as  a  small  papule,  from  the 
covering  of  which  a  clear  serum  escapes,  or  from  the  beginning  it  may 
exist  as  an  erosion.  There  may  be  one  or  many,  owing  to  the  number 
of  points  simultaneously  inoculated. 

An  uncomplicated  initial  lesion,  not  subjected  to  irritation,  does  not 
tend  to  ulcerate.  It  is  usually  circular  or  oval  in  outline,  is  shallow,  in- 
creasing gradually  in  depth  from  the  periphery  toward  the  center,  and 
its  surface  is  covered  with  a  yellow  serous  transudation. 

Grrasped  between  the  thumb  and  finger,  it  is  found  to  be  indurated, 
not  painful.  The  induration  is  closely  limited  to  the  sore,  and  terrai- 
nates  rather  abruptly,  not  fading  off  gradually  in  a  wide  infiltration  of 
the  skin  or  neighboring  tissues. 

When  the  specific  ulcer  of  syphilis  is  inoculated  with  a  virus  which 
induces  phagedena,  its  peculiar  character  is  lost,  and  it  becomes  in  ap- 
peai^nce  and  behavior  a  non-s]pecific  sore.  If  from  friction  or  the  appli- 
cation of  corrosive  substances,  or  the  cautery,  an  acute  inflammation  is 
precipitated,  the  specific  character  of  the  lesion  also  disappears. 

Local  lymphangitis  and  adenitis  always  occur  in  syphilis  during  the 
formation  and  existence  of  the  initial  ulcer.  Commencing  in  the  lymph- 
channels  immediately  around  the  lesion,  the  process  travels  in  the  direc- 
tion of  the  nearest  glands.  If  the  sore  is  well  on  one  side,  the  glands  of 
that  side  are  usually  first  affected.  When  situated  in  the  median  line, 
or  if  ulcers  exist  on  both  sides,  the  adenitis  is  apt  to  be  bilateral.  In 
very  exceptional  cases,  ulcer  of  one  side  is  followed  by  unilateral  ade- 
nitis on  the  opposite  side  of  the  body.  Dating  from  the  appearance  of 
the  sore,  from  eight  to  fourteen  days  usually  elapse  before  enlargement 
of  the  inguinal  glands  is  noticed.  Less  frequently,  three  or  four  weeks 
intervene. 

Prom  one  to  seven  distinct  glandular  nodules  may  be  felt.  They  are 
hard,  yet  slightly  elastic  to  the  touch,  not  painful  under  ordinary  press- 
ure, and  freely  movable  beneath  the  skin.  The  size  varies  from  those 
which  are  so  small  as  scarcely  to  be  recognized  up  to  a  half-inch  or  more 
in  diameter.  There  is  no  periadenitis,  and,  unless  an  acute  or  phage- 
denic inflammatory  process  is  superadded,  the  glands  do  not  become 
matted  together  in  one  hard,  painful  lump,  nor  does  the  integument  be- 
come red  and  painful,  as  in  the  adenitis  of  phagedenic  ulcer  or  gonor- 
rhoea. 

The  primary  adenitis  continues  into  the  second  stage,  in  which  indu- 
ration of  the  glands  is  general. 


720  A  TEXT-BOOK   ON  SURGERY. 

When  the  ulcer  is  situated  upon  the  lips,  tongue,  or  mouth,  the  sub- 
maxillary plexus  becomes  enlarged.  Adenitis  of  the  epitrochlear  and 
axillary  glands  follows  inoculation  upon  the  lingers,  hand,  or  foreami. 

Second  Stage. — Cutaneous  and  mucous  lesions,  alopecia,  fever,  head- 
ache, arteritis,  lymphangitis,  adenitis,  iritis,  and  osteitis. 

The  cutaneous  lesions  of  syphilis  {sypldUdes)  may  be  macular, 
papular,  vesicular,  pustular,  and  tubercular.  Of  these  forms  of  erup- 
tion, some  are  pecaliar  to  the  secondary  period,  others  to  the  tertiary, 
while,  as  will  be  seen,  some  are  met  with  in  both  the  second  and  third 
stages. 

The  macular  syphilide  is  usually  first  seen  occurring  as  indistinct 
spots  or  stains,  not  elevated,  and  varying  from  a  light  red  to  a  slate  or 
copper  color.  They  appear  very  frequently  at  the  limit  of  the  first  stage 
of  syphilis,  about  the  sixth  or  seventh  week  after  the  ulcer  occurs,  but 
often  later  than  this  period.  The  portion  of  the  body  where  the  maculae 
are  usually  first  seen  is  upon  the  abdomen,  whence  they  may  extend  over 
the  entire  cutaneous  surface.  In  size  they  vary  from  a  pin-head  to  round 
or  oval  spots  a  half-inch  or  more  in  diameter. 

The  papular  syphilide  occurs  in  several  forms  which  may  be  present 
in  the  secondary  or  tertiary  period.  The  mucous  surfaces,  as  well  as 
the  integument  proper,  are  affected.  Not  infrequently  the  papulae  are 
preceded  or  accompanied  by  maculae.  The  papulae  assume  various 
shapes,  some  being  small  and  pointed,  others  broader  at  the  base  and 
flat  on  top,  in  shape  like  a  truncated  cone.  Upon  mucous  surfaces  the 
papular  character  of  the  eruption  may  be  observed  if  seen  early  in  its 
appearance ;  but,  on  account  of  the  moisture  present,  the  papules  soon 
disappear,  leaving  patches  which  may  be  elevated  or  depressed.  Mucous 
patches.,  when  recent,  are  red  in  color,  but  later  become  covered  with  a 
grayish  film. 

The  paj)ular  syphilide,  which  occurs  near  the  junction  of  the  skin 
and  mucous  surfaces,  or  in  the  deep  folds,  as  those  below  the  mammary 

glands  in  women,  and  the  thighs 
^'  and  gluteal  regions  in  fleshy  in- 

dividuals of  either  sex,  not  in- 
frequently, as  a  result  of  un- 
cleanliness  and  irritation,  be- 
comes developed  into  papillary 
or  warty  growths  known  as  con- 
dylomata (Fig.  652). 

The  eruption  comes  out   in 
.  "^'x,                       '  some  cases  over  the  entire  body ; 

^'^ — ^____  "- in  others  the  face  is  exempt. 

Fig.  652.— Vegetating  condylomata  of  the  vulva.  ^^®  palmS  Of  the  hauds  and  the 

(After  Bumstead  and  JuUien.)  goles  of  the  feet  are  uot  infre- 

quently invaded.  At  times  the 
trunk  is  chiefly  occupied ;  the  face,  hands,  and  feet  escaping.  The  mar- 
gins of  the  papulae  are  well  defined,  varying  in  size  as  did  the  maculae, 
and  also  in  color.     In  the  main  they  are  darker,  and  the  pigmentation 


w 

^^^^ 

'f^5^ 

s      K 

iTK.'^ 

" 

(r 

SYPHILIS.  721 

is  more  marked.  The  eruption  disappears  by  absorption  of  the  cells 
which  have  infiltrated  the  j)apillse  and  corium,  and  this  may  occur  with 
or  without  desiccation  or  scaling.  The  scaling  sypMlide,  or  so-called 
psoriasis  sypliilitica,  is  at  times  with  difficulty  differentiated  from  true 
psoriasis,  especially  when  the  venereal  inoculation  is  denied. 

The  vesicular  syphilide  is  peculiar  to  the  second  stage,  and  is  seldom 
observed.  The  vesicles,  like  the  papules,  may  be  small,  pointed,  and 
gathered  in  clusters,  as  in  heqDes  ;  or  larger,  like  the  vesicles  of  chicken- 
pox,  and  scattered  at  varying  intervals  over  the  entii'e  body.  Commenc- 
ing as  vesicles,  they  may  become  pustules,  which,  as  evaporation  occui's, 
are  covered  with  small  crusts  or  scabs. 

The  pustular  syphilide  may  be  met  with  on  all  parts  of  the  body, 
and  may  originate  as  a  pustule,  or,  as  stated  above,  become  pustular 
from  a  vesicular  or  papular  origin.  This  variety  of  cutaneous  lesion, 
while  most  common  in  secondary,  is  not  infrequently  seen  in  tertiary 
syphilis.  The  smaller-sized,  more  superficial  pustules,  belong  naturally 
to  the  earlier  period  ;  those  with  wide  bases  and  more  extensive  tissue- 
destruction,  to  the  later  manifestations. 

The  pustular  syphilide  originates  around  and  in  the  hair-follicles. 
In  mild  cases,  and  when  of  small  size,  the  limit  of  infiltration  and  pus- 
tulation  is  immediately  around  the  follicle.  In  other  cases  the  infiltra- 
tion is  wider,  and  the  destructive  process  more  extensive. 

Scabbing,  with  underlying  ulcei-ation  varying  in  extent,  is  the  com- 
mon history  of  all  pustular  syphilides,  although  extensive  molecular 
death  of  tissue  is  less  apt  to  occur  in  the  secondary  than  in  the  tertiary 
stage.  The  color  of  the  crusts  varies  from  black  to  a  brownish-copper 
color.  If  the  scab  is  removed,  the  walls  of  the  ulcer  will  be  seen  to  be 
precipitate  and  curvilinear  in.  outline,  while  the  floor  is  covered  with  a 
varying  amount  of  fluid  and  detritus. 

The  tubercular  syj)hilide  is  so  rarely  a  lesion  of  secondary  syphilis 
that  it  will  be  described  with  the  symptoms  of  the  third  stage  of  this 
disease. 

It  is  exceedingly  rare  to  observe  all  of  the  foregoing  syphilides  in 
any  single  individual.  The  macular  and  papular  eruptions  are  fre- 
quently met  with  together,  while  the  pustular  syphilide  usually  exists 
alone. 

Alopecia  occurs  in  a  varying  degree  in  most  cases  of  syphilis. 
Though  noticed  chiefly  in  the  scalp  and  beard,  all  the  hairy  portions 
of  the  body  are  involved.  Except  in  the  case  of  the  pustular  syphilide, 
the  follicles  are  rarely  destroyed,  so  that,  as  the  violence  of  the  attack 
is  diminished,  the  hairs  are  reproduced.  Alopecia,  from  general  sebor- 
rhoea,  is  one  of  the  later  manifestations  of  syphilis. 

Fever. — Elevations  of  temperature  occur  in  the  second  stage  of  syphi- 
lis in  a  large  proportion  of  cases.  In  mild  attacks  it  may  not  be  ob- 
served, but  in  many  instances  the  thermometer  vdll  register  from  one  to 
two  or  three  degrees  above  the  normal.  The  febrile  movement  usually 
begins  when  the  virus  has  passed  through  the  first  network  of  lymphat- 
ics and  is  being  disseminated  throughout  the  tissues.  It  may  precede 
46 


722  A  TEXT-BOOK  ON   SURGERY. 

the  ernption  or  occur  with  it,  and,  as  a  rule,  continues  after  the  eruption 
fades  away. 

Headache,  usually  referred  to  the  frontal  region,  at  times  to  the  ver- 
tex or  base,  occurs  during  the  period  of  fever,  and  is  generally  propor- 
tionate to  the  intensity  of  the  febrile  movement. 

Arteritis^  lymphangitis,  and  general  adenitis  occur  in  the  second 
stage,  and,  in  neglected  cases,  continue  until  the  third  stage.  Iritis  is 
not  uncommon  in  secondary  syphilis.  It  is  usually  unilateral,  and  may 
be  recognized  by  immobility  of  the  iris,  photophobia,  and  by  the  injec- 
tion of  the  membrane. 

Pathological  changes  in  the  bones  do  not  occur,  as  a  rule,  in  the  ear- 
lier stages  of  syphilis.  Pain,  usually  mild  in  character,  is  present  in 
some  cases  in  the  second  stage,  but  lesions  of  the  osseous  structures  be- 
long especially  to  the  last  stage  of  this  disease. 

Tliird  Stage. — The  lesions  of  tertiary  syphilis  manifest  themselves 
not  earlier  than  the  second  year  of  the  disease.  Once  present  they 
may  continue  for  a  while,  and  disappear,  to  return  at  varying  intervals 
during  the  life  of  the  individual.  No  tissue  or  organ  is  exempt  from 
the  grave  pathological  changes  induced  by  the  syphilitic  virus  in  this 
stage. 

Skin. — Externally,  the  changes  in  the  skin  are  chiefly  those  of  ulcera- 
tion. Nodules,  resulting  from  cell-proliferation  and  accumulation  in  the 
deeper  layers  of  the  skin,  and  at  times  in  the  subcutaneous  tissues  {gum- 
mata),  appear,  and  after  existing  for  a  variable  period  of  time  may,  by 
interference  with  the  nutrition  of  the  part,  lead  to  molecular  death  of 
the  adjacent  tissues,  or,  failing  in  this,  undergo  fatty  metamorphosis  and 
absorption.  If  an  ulcer  exists,  it  has  the  usual  shape  of  the  syphilitic 
sore — round,  oval,  or  curvilinear,  with  regular  edges,  not  ragged  or  in- 
dented. When  granular  degeneration  of  the  new  tissue  occurs,  the  skin 
immediately  over  the  tubercle  has  a  stretched  or  glazed  appearance,  and 
is  slightly  discolored. 

A  not  infrequent  pustular  cutaneous  lesion  of  the  third  stage  of 
syphilis  is  known  as  rupia  syphilitica.  In  very  rare  instances  a  pus- 
tular syphilide,  similar  in  appearance  and  with  difficulty  differentiated 
from  rxipia,  occurs  as  a  secondary  lesion.  I  presented  one  such  case, 
with  an  unmistakable  history  of  acute  syphilis,  to  the  New  York  Patho- 
logical Society  in  1884.  The  pustules  in  rupia  syphilitica  are  usually 
circular  or  oval  in  shape,  appear  as  slight  elevations  or  blebs,  which  soon 
break  open.  The  sero- purulent  contents  ooze  out ;  evaporation  and  scab- 
bing occur ;  the  crusts,  by  reason  of  the  new  deposit  underneath,  are 
gradually  lifted,  and  give  to  the  scab  a  laminated,  rough  appearance, 
not  unlike  that  of  an  oyster-shell.  The  crusts  have  a  dark-brown  or 
slightly  greenish  hue. 

When  the  late  cutaneous  lesions  of  syphilis  attack  the  fingers,  the  nail 
or  matrix  is  affected  (paronychia),  causing  a  roughened  condition  of  the 
nail  and  a  swollen  matrix,  leading  frequently  to  temporary,  and  occa- 
sionally to  permanent,  loss  of  the  organ.  In  like  manner,  permanent 
alopecia  may  occur  from  destruction  of  the  hair-follicles. 


SYPHILIS.  723 

J^ervous  System — Brain. — Paralysis  is  one  of  the  more  frequent  le- 
sions of  tertiary  syphilis,  and  may  result  from  one  of  several  causes, 
namely — pressure  of  a  gumma  developed  within  the  brain-substance 
proper  or  upon  the  investments  ;  pressure  from  syphilitic  exostosis  of 
the  skull ;  destruction  of  brain-cells  by  connective-tissue  hyperplasia  in 
the  neuroglia,  with  consequent  cicatrization  and  contraction ;  more  or 
less  complete  occlusion  of  the  arteries  {endarteritis  obliterans'). 

Hemiplegia,  partial  or  complete,  is  the  rule.  Occasionally  the  center 
of  language  is  alone  affected.  Dementia  may  ensue  as  a  result  of  soft- 
ening or  pressure,  and  epilepsy  may  be  classed  among  the  late  manifesta- 
tions of  this  disease. 

Chronic  meningitis  is  an  occasional  symptom  of  late  syphilis.  It  is 
accompanied  by  headache,  dull  and  persisting  in  character,  imioairment 
of  intellect,  interference  with  the  functions  of  one  or  more  of  the  cranial 
nerves  by  extension  of  the  morbid  process,  resulting  at  times  in  ptosis, 
strabismus,  or  impairment  of  vision,  hearing,  taste,  smell,  etc.  The  more 
serious  cases  progress  gradually  to  coma  and  death.  There  is  in  aU  an 
elevation  of  temperature,  loss  or  impairment  of  appetite,  and  derangement 
of  the  entire  digestive  apparatus. 

The  spinal  cord  and  its  membranes,  though  less  frequently  attacked 
than  the  brain,  may  be  involved  as  a  result  of  similar  pathological  con- 
ditions. Paraplegia  more  or  less  comj)lete  ensues,  involving  at  times 
the  bladder  and  rectum.  In  milder  cases  co-ordination  is  disturbed,  with 
little  or  no  loss  of  muscular  power.  Pain  may  be  present,  referred  to 
the  back  at  or  near  the  seat  of  the  lesion,  or  along  the  distribution  of  the 
sensory  nerves,  or  anaesthesia  may  occur. 

One  or  more  of  the  nerves,  sensory  or  motor,  may  in  like  manner  be 
affected  as  a  result  of  the  development  of  gummata,  or  connective-tissue 
changes  in  the  neurilemma,  or  the  pressure  of  exostoses  or  other  neo- 
plasms. 

Bones. — Periostitis  and  ostitis,  especially  in  those  portions  of  the 
skeleton  most  exposed  to  sudden  changes  in  temperature  and  to  direct 
violence,  are  among  the  more  frequent  lesions  of  tertiary  syphilis.  The 
bones  of  the  skull,  the  spine  of  the  tibia,  and  the  clavicle,  are  more  often 
involved.  The  swelling  caused  by  the  inflammatory  exudation  may  be 
readily  appreciated  by  palpation,  and  pain  or  tenderness  is  present  on 
direct  pressure.  The  tumefaction  results  from  the  formation  of  new 
bone  (exostosis),  which  in  some  instances  persists  indefinitely. 

Gummata.  are  developed  upon  or  beneath  the  periosteum,  forming 
soft,  semi-fluctuating  swellings,  usually  ciiTular  in  shape,  and  from  a 
half-inch  to  an  inch  or  two  in  diameter.  These  tumors  or  nodes,  while 
not  very  painful  under  ordinary  pressure,  are  the  seat  of  exacerba- 
tions of  pain  which  are  usually  experienced  at  night.  Thsy  freq^^ent- 
ly  break  down  in  a  process  of  ulceration  which  involves  the  underly- 
ing bone. 

^ATien  the  inflammatory  process  is  violent,  extensive  necrosis  may 
occur.  A  peculiar  tyj^e  of  ostitis  in  the  later  manifestations  of  syphilis 
is  that  known  as  osteitis  rarefaciens,  in  which  there  is  no  suppui-ation  or 


724  A  TEXT-BOOK  ON  SURGERY. 

exfoliation,  a  portion  of  the  bone-substance  undergoing  absorption, 
giving  to  the  part  involved  a  porous  or  worm-eaten  appearance. 

Hypertrophy  of  the  bones,  even  to  a  remarkable  degree,  is  not  un- 
common, and  may  be  due  to  the  development  of  compact  substance 
beneath  the  periosteum,  or  the  entire  cancellous  portion  may  be  replaced 
by  this  eburnated  tissue.  On  the  other  hand,  the  hypertrophy  is  in 
some  cases  entirely  cancellous  in  character,  the  bone  taking  on  two  or 
three  times  its  natural  thickness. 

Joints. — The  pathological  changes  in  bone  may  also  be  accompanied 
by  like  changes  in  the  articulations. 

Synonitis,  with  thickening  of  the  membrane  and  surrounding  cap- 
sule, is  present,  accompanied  by  impairment  of  motion  and  pain  of  a  dull 
character.  In  severer  cases,  the  cartilages  and  bones  become  involved, 
leading  to  osteo-arthritis  and  destruction  of  the  joint. 

Heart  and  Vessels. — Patty  degeneration  of  the  heart-muscle,  follow- 
ing syphilitic  myocarditis,  and  the  formation  of  gummata  upon  the  peri- 
cardium or  within  the  muscular  walls,  are  the  chief  lesions  of  this  organ 
in  the  tertiary  period.  The  pericardium  may  also  be  affected,  and  in 
like  manner  the  endocardium,  which  may  undergo  atheromatous  degen- 
eration or  give  rise  to  vegetations.  Of  the  vessels,  the  capillaries  always 
affected  in  the  first  and  second  stages,  are  not  so  seriously  involved  in 
the  last  stage  as  the .  arteries.  The  veins  are  rarely  affected.  Arteritis, 
especially  the  variety  known  as  endarteritis  obliterans.,  is  one  of  the 
most  common  and  grave  lesions  of  chronic  syphUis.  While  the  larger 
trunks  are  involved,  the  more  characteristic  changes  occur  in  the  terminal 
arteries  and  arterioles.     The  cerebral  vessels  are  especially  susceptible. 

Lymphatics. — Gummatous  deposits  occasionally  take  place  in  the 
lymphatic  glands  in  tertiary  syphilis.  The  superficial  set  may  break 
down  and  discharge  their  contents.  The  deep  glands  undergo  granular 
degeneration  with  absorption,  or  the  gummatous  material  undergoes  the 
caseous  or  calcareous  degeneration. 

Respiratory  System — Nose. — The  mucous  membrane  may  be  thick- 
ened, or  may  be  more  or  less  destroyed  by  ulceration.  The  cartilage 
and  bony  framework  of  this  organ  are  very  often  destroyed. 

Larynx. — The  mucous  membrane  of  the  larynx  may  also  be  thick- 
ened, or  the  seat  of  ulcers  or  vegetations.  Chondritis  and  perichondritis 
are  not  infrequent ;  and,  as  a  result  of  the  chronic  inflammation,  stricture 
and  stenosis,  more  or  less  complete,  may  occur  from  cicatricial  contrac- 
tion. It  may  also  be  the  seat  of  gummata.  The  trachea  and  bronchi  are 
subject  to  similar  lesions,  inducing  stricture. 

In  the  lungs  the  principal  lesions  are — (1)  chronic  interstitial  or  fibrous 
pneumonia ;  (2)  more  or  less  widely  disseminated  gummatous  deposits, 
usually  in  the  lower  portions  of  these  organs. 

Digestive  System — Mouth. — Superficial  ulcers  of  the  walls  of  the 
buccal  cavity  are  not  infrequent ;  deep,  destructive  ulcers  are  rare.  This 
can  not,  however,  be  said  with  truth  concerning  the  palate,  where,  as  a 
result  of  gummatous  deposits  or  general  infiltration,  the  most  rapid  and 
irreparable  destruction  of  tissue  may  occur.     The  curtain  of  the  soft 


SYPHILIS.  725 

palate  is  frequently  destroyed,  the  bony  septum  between  the  mouth  and 
nose  is  perforated,  while  in  extreme  cases  the  pillars  of  the  fauces  and 
the  pharynx  are  involved.  Other  lesions  of  the  pharynx  do  not  differ 
from  those  of  the  buccal  cavity. 

Tongue. — Gummatous  deposits  may  occur  in  any  portion  of  this 
organ,  causing  local  or  general  tumefaction.  Whether  superficial  or 
deep,  they  tend  to  break  down,  giving  rise  to  ulcers  varying  in  size  and 
depth.  The  other  principal  lesion  of  the  tongue  in  the  tertiary  period  is 
more  or  less  widely  diffused  connective-tissue  hyperplasia,  giving  rise  to 
a  varying  degree  of  enlargement.  As  the  new-formed  tissue  contracts  it 
gives  to  the  organ  a  lobulated  appearance,  the  boundaries  of  the  lobules 
being  well-marked  fissures  in  the  line  of  the  contracting  bands. 

CEsopJiagus. — Partial  or  complete  occbision  of  the  oesophagus  may 
occur  from — (1)  connective-tissue  hyperplasia  in  its  walls,  or  the  contrac- 
tion following  ulcer  (organic  stricture) ;  (2)  the  mechanical  obstruction 
from  gummatous  deposits  in  the  walls  or  in  the  immediate  neighborhood 
of  the  oesophagus ;  (3)  pressure  from  exostoses,  aneurisms,  enlarged 
glands,  etc.  Syphilitic  iilcers  of  the  stomach  and  alimentary  canal  have 
been  observed,  though  rarely.  Gummata  form  here,  however,  with  a 
certain  degree  of  frequency,  and  stricture  of  the  pylorus,  and  of  the  in- 
testinal canal  above  the  rectum,  is  known  to  occur  in  a  certain  propor- 
tion of  cases.  The  rectum  is  especially  liable  to  become  seriously  in- 
volved in  the  late  manifestations  of  syphilis.  Here,  as  elsewhere,  strict- 
ure may  result  from  fibrillation  and  contraction  of  the  inflammatory  tissue 
with  which  the  walls  of  this  organ  and  the  peri-rectal  tissues  may  be- 
come infiltrated.  Again,  ulcers  originating  within  the  gut,  or  extending 
from  a  like  inflammatory  process  about  the  anus  and  the  external  tissues, 
or  the  presence  of  gummatous  material,  may  all  induce  more  or  less 
serious  contraction  of  the  lumen  of  the  rectum.  Of  the  solid  abdominal 
viscera,  the  limr  is  most  seriously  affected.  The  pathological  changes 
are — (1)  connective-tissue  hyperplasia  or  chronic  interstitial  hej^atitis  or 
syphilitic  cirrhosis,  which  may  be  general  or  local ;  (2)  gummata  in  any 
portion  of  the  organ  ;  (3)  waxy  degeneration  from  long-continued  general 
sepsis. 

The  spleen  may  undergo  similar  changes.  Slight  enlargement  may 
occur  from  the  excess  of  white  corpuscles  (leucocythsemia),  which  is  the 
rule  in  this  disease. 

The  pancreas  is  rarely  affected. 

Genito-urinary  System. — Amyloid  degeneration  of  the  kidneys  oc- 
curs as  a  result  of  the  long-continued  sepsis  of  syphUis,  as  with  other 
chronic  forms  of  blood-poisoning.  In  like  manner,  under  conditions  fa- 
vorable to  connective-tissue  hyperplasia,  the  fibrous  stroma  of  this  organ 
becomes  thickened,  with  consequent  atrophy  of  the  excretory  or  glandu- 
lar elements  (chronic  interstitial  nephritis). 

Crummata  of  the  kidney  is  not  as  common  as  in  other  viscera. 

Orchitis,  although  occurring  while  some  of  the  secondary  symptoms 
may  be  present,  is  essentially  a  late  manifestation  of  this  disease.  It  is 
important  to  recognize  it,  since  several  varieties  of  sarcocele  require  im- 


726  A  TEXT-BOOK  ON   SURGERY. 

mediate  surgical  interference.  Syphilitic  orchitis  should  be  suspected 
in  all  cases  of  tumor  of  this  organ  in  which  there  is  a  history  of  specific 
infection.  In  syphilis,  the  enlargement  is  apt  to  occur  in  both  organs 
about  the  same  time.  The  growth  is  smooth  and  spherical,  and  when 
lifted  conveys  the  sense  of  unusual  weight.  It  is  not  painful,  excepting 
always  the  sense  of  dragging,  which  is  at  times  annoying.  Slight  hydro- 
cele not  infrequently  accompanies  this  form  of  orchitis. 

The  testicles  are  not  exempted  from  gummatous  deposits.  In  rare  in- 
stances these  break  down,  causing  more  or  less  destruction  of  the  sub- 
stance of  these  organs.  The  penis  is  occasionally  the  seat  of  syphilitic 
infiltration  in  the  later  stages  of  this  affection. 

The  Eye. — Syphilitic  iritis  has  been  given  as  occurring  in  the  second 
stage  of  this  disease.  It  may  also  occur  as  a  later  manifestation.  In- 
flammation of  the  sclera,  choroid  and  ciliary  bodies,  lens  and  capsule, 
retina,  and  (though  rarely)  of  the  optic  nerve,  are  of  varying  frequency 
in  the  tertiary  period.  Lesions  of  the  muscles  may  be  due  to  connective- 
tissue  new  formations  between  the  fasciculi,  resulting  in  granular  degen- 
eration of  the  muscle-substance  and  contraction  of  the  new  tissue.  It 
nay  occur  in  the  second  as  well  as  the  third  stage  of  this  disease.  These 
contractions,  if  not  relieved,  may  result  in  anchylosis  of  the  joint  in  im- 
mediate anatomical  relation  to  the  muscles  involved.  Gummata  are  not 
of  frequent  occurrence.  They  terminate  by  suppuration  or  by  absorp- 
tion.    Inflammation  in  the  tendons  and  their  sheaths  may  also  occur. 

Fingers  and  Toes. — The  fingers  and 
^ — --.  toes,  during  the  tertiary  period  of  syph- 

^^  \^  ilis,  in  a  certain  proportion  of  cases  be- 

come the  seat  of  gummatous  deposits, 
the  skin  and  subcutaneous  tissues  may 
be  infiltrated,  or  the  bones  and  cartilages 
may  be  involved.  When  the  infiltration 
is  confined  to  the  soft  parts,  the  entire 

iiG.  653.— Syphilitic  dactylitis.  .,,  ,,  -^  ' 

(After  Bergii  and  Bumst'ead.)  orgau  Will  appear  swoUeu  and  purple  or 

reddish  in  color.  When  the  bone  is  the 
seat  of  the  deposit,  it  may  be  limited  to  a  single  phalanx  (Fig.  653)  or 
invade  all  the  bones  of  the  finger.  The  process  terminates  in  ulcer, 
necrosis,  or  granular  degeneration  of  the  cells  of  the  new  tissue,  and 
absorption. 

Pathology  of  Syphilis.— Tlxa  chief  feature  in  the  pathology  of  syphi- 
lis in  all  of  its  stages  is  the  proliferation  of  an  embryonic  tissue,  usually 
of  a  type  so  low  that  it  is  not  capable  of  organization  into  a  definite 
tissue.  From  the  initial  lesion  and  the  primary  lymphangitis  and  ade- 
nitis to  the  final  lesions  of  the  viscera,  this  cell-proliferation  continues, 
and  the  different  effects  witnessed  in  different  individuals,  or  in  the  same 
individual,  in  the  various  stages  of  the  disease,  depend  chiefly  upon  the 
degree  of  impairment  in  the  nutrition  of  the  tissues.  The  cell-accumu- 
lation in  and  around  the  capillary  loops  of  the  cutaneous  papillje,  which 
produce  a  macular  or  papular  syphilide  in  one  individual  whose  tissues 
are  in  a  condition  of  perfect  nutrition,  will  produce  a  squamous  or  vesic- 


PATHOLOGT  OP  SYPHILIS.  '727 

ular  eruption  in  another,  or  a  pustular  sypliilide  in  a  third  who  has  the 
unfortunate  inheritance  of  a  gouty,  scrofulous,  or  tubercular  dyscrasia. 
Or  a  papular  lesion  of  the  first  stage,  in  which  the  process  of  nutrition 
in  the  tissues  is  normal,  may  be  replaced  by  a  rupia  in  the  tertiary  pe- 
riod when  assimilation  is  less  perfect. 

If  the  initial  lesion  of  syphilis  is  excised  and  examined  with  the  mi- 
croscope, the  following  conditions  will  be  observed  :  The  epidermis  in 
the  immediate  vicinity  of  the  nicer  is  more  or  less  completely  destroyed. 
The  membrane  which  covers  the  floor  of  the  ulcer  is  composed  of  pus- 
cells,  fragments  of  epidermal  cells,  cells  of  the  Malpighian  layer,  and 
fragments  of  connective-tissue  and  other  detritus.  These  elements  vary 
in  proportion  as  the  process  of  necrobiosis  is  limited  or  extensive.  In 
the  deeper  portions  of  the  Malpighian  layer,  and  in  and  around  the  pa- 
pillae where  these  layers  are  not  wholly  destroyed,  and  in  the  connective- 
tissue  layer  of  the  skin,  there  is  a  general  infiltration  with  the  embry- 
onic cells  of  the  syphilitic  process. 

The  arterioles,  veins,  and  capillaries  are  more  or  less  completely  oc- 
cluded. The  cell-proliferation  is  especially  marked  in  the  arterioles,  the 
adventitia  and  intima  are  thickened,  the  thickening  being  more  marked 
in  the  latter,  while  the  lumen  of  the  vessel  is  more  or  less  encroached 
upon  by  the  new-formed  tissue.  The  venules  undergo  analogous  changes. 
The  walls  of  the  lymph-channels  are  thickened,  and  many  of  these  ves- 
sels are  crowded  with  cells.  The  infiltration  is,  however,  limited  to  the 
immediate  borders  of  the  ulcer,  and  the  line  between  this  and  the  unin- 
vaded  tissue  is  sharply  defined.  As  the  mass  of  cells  gradually  obstruct 
the  vessels,  the  nutrition  of  the  new  tissue  is  interfered  with,  and  it  either 
undergoes  granular  metamorphosis  or  breaks  down  more  rapidly  as  a 
slough.  The  absence  of  pain  in  the  chancre  is  also  exjalained  by  the 
gradual  pressure  upon  the  terminal  nerves  and  the  comparative  dryness 
of  the  typical  sore  to  the  arterial  occlusion. 

The  lym,p7iatics  immediately  around  the  ulcer,  and  those  leading  from 
it  to  the  nearest  glands,  are  more  or  less  filled  with  the  new  cells,  and 
their  walls  apjDear  thicker  than  normal. 

The  changes  which  occur  in  the  glands  in  the  earlier  stages  of  syphi- 
lis consist  in  a  hyperplasia  of  the  connective- tissue  cells  of  the  stroma 
and  thickening  of  the  fibrous  framework,  together  with  an  increase  in 
the  cell-eletnents  of  the  gland-substance  proper. 

The  cutaneous  lesions  of  secondary  syphilis  result  from  the  more  or 
less  complete  obstruction  of  the  capillary  loops  of  the  papillae  by  the 
cells  of  this  indifferent  tissue.  The  walls  of  the  capillaries  undergo  de- 
generation ;  the  coloring-matter  of  the  blood  escapes,  causing  the  pecul- 
iar staining  of  the  syphilides.  In  the  macular  syphilide  the  abnormal 
cell-accumulation  is  less  than  in  the  papular  eruption.  The  changes 
which  occur  in  mucous  patches  differ  very  slightly  from  those  described 
in  the  cutaneous  lesions.  The  epidermis  soon  breaks  down  ;  the  Malpig- 
hian layer  and  papilla?  are  infiltrated  with  the  cell-elements  ;  while  the 
capillaries,  arterioles,  and  lymphatic  vessels  undergo  changes  almost 
identical  with  those  described  in  the  initial  lesion. 


728  A  TEXT-BOOK  ON  SURGERY. 

In  the  later  or  tertiary  lesions  of  the  skin  in  syphilis,  the  infiltration 
is  deeper.  Cutaneous  gummata  consist  of  aggregations  of  the  cell-ele- 
ments heretofore  described,  which  are  crowded  into  the  subcutaneous 
areolar  tissue,  into  the  connective  tissue  of  the  true  skin,  in  the  walls  of 
and  just  outside  the  vessels,  while  the  endothelia  of  these  vessels  under- 
go proliferation  and  aid  in  their  occlusion.  Ulceration  ensues  from  the 
rapid  arrest  of  nutrition,  and  the  process  of  necrobiosis  is  aided  by  the 
depressed  condition  of  the  tissues  which  usually  exists  in  the  tertiary 
stage  of  syphilis.  The  tertiary  lesions  of  the  mucous  surfaces  are  analo- 
gous to  those  of  the  integument. 

The  pathology  of  visceral  syphilis  presents  two  distinct  morbid  pro- 
cesses :  (1)  the  hyperplasia  of  the  connective-tissue  stroma  of  the  organs 
(cirrhosis) ;  and  (2)  the  aggregation  of  the  syphilitic  embryonic  cells 
(gumma).  The  character  of  these  changes  in  the  different  organs  has 
been  given. 

Diagnosis.— In  a  typical  case  of  acquired  syphilis  a  diagnosis  may 
be  made  upon  the  follovping  symptoms :  1,  an  ulcer  in  appearance  and 
behavior  like  that  described  as  belonging  to  the  initial  lesion  of  this 
disease,  the  sore  occurring  not  less  than  ten  days,  and  usually  about  the 
twentieth  day,  after  an  exposure  ;  2,  induration  and  enlargement  of  the 
nearest  lymphatic  glands  occurring  in  from  eight  to  fourteen  days  after 
the  appearance  of  the  ulcer  ;  3,  after  from  two  to  four  weeks  of  seeming 
arrest  of  the  infection,  the  development  of  headache,  pain  in  the  back, 
slight  febrile  movement,  with  an  eruption  (sixth  to  seventh  week  after 
the  appearance  of  the  sore)  over  all  or  a  portion  of  the  body,  accom- 
panied with  an  unusual  sense  of  dryness  or  soreness  of  the  mouth,  phar- 
ynx, or  fauces ;  4,  following  or  occurring  with  these  symptoms,  general 
adenitis. 

In  the  majority  of  cases,  excluding  even  those  in  which  the  sore  is 
concealed,  as  in  the  urethra,  etc.,  little  value  can  be  placed  upon  the 
appearance  of  the  ulcer  at  the  point  of  infection.  The  classical  "initial 
lesion"  of  syphilis,  with  its  well-defined  margin  of  induration,  feeling 
like  a  "split  pea"  or  piece  of  cartilage  when  grasped  betv/een  the  thumb 
and  finger ;  the  absence  of  pain  and  peripheral  inflammation ;  the  pe- 
culiar "  scooped-out "  concavity  of  the  sore,  the  surface  of  which  is  cov- 
ered with  a  scanty,  serous  transudation,  is  so  frequently  absent  in  cases 
in  which  the  later  and  unmistakable  signs  of  this  disease  are  developed, 
that  it  alone  can  not  be  relied  upon  in  arriving  at  a  diagnosis.  As  stated 
heretofore,  the  syphilitic  virus  may  be  lodged  in  and  absorbed  from  a 
phagedenic  ulcer  in  which  not  a  single  feature  of  the  specific  sore  is 
present.  The  same  is  true  of  the  herpetic  ulcer,  or  that  resulting  from 
traumatism  or  the  inoculation  of  any  form  of  virus.  All  of  these  ulcers 
are  grouped  under  the  heading  of  "mixed  sores." 

Induration  of  the  glands  is  more  reliable  in  a  diagnostic  sense.  When 
the  typical  initial  lesion  is  present,  the  ensuing  adenitis  is  also  typical. 
In  the  inguinal  region  one  gland  of  the  group  after  another  is  enlarged 
and  becomes  indurated.  The  process  is  slow  and  deliberate.  There  is 
no  periadenitis,  the  glands  do  not  adhere  to  each  other  and  the  interven- 


DIAGNOSIS   OF  SYPHILIS.  729 

ing  tissues,  nor  to  the  integument.  Eacli  body  may  be  distinctly  made 
out  by  palpation  and  moved  beneath,  the  skin  independently.  There  is 
no  tenderness,  and  the  gland  is  leathery  to  the  touch.  Even  when  the 
sore  is  mixed,  if  the  phagedenic  or  inflammatory  process  is  not  severe, 
the  adenitis  is  more  apt  to  be  specific  than  inflammatory,  and  will  pos- 
sess the  features  of  syphilitic  bubo  in  a  sufficient  degree  to  admit  of 
recognition.  "When  the  specific  infection  is  complicated  with  a  typical 
phagedenic  ulcer  or  gonorrhcea,  the  resulting  bubo  does  not  possess  a 
single  appreciable  feature  of  syphilitic  adenitis. 

The  eruption  of  syphilis  is,  of  all  the  symj)toms  of  this  disease,  the 
most  reliable.  When  the  sore  is  mixed,  and  the  character  of  the  ade- 
nitis doubtful,  the  early  cutaneous  and  mucous  lesions  are,  in  the  vast 
majority  of  cases,  appreciable  and  unmistakable.  Headache,  rise  in  tem- 
perature, pains  in  the  back,  etc.,  are  confirmatory  symptoms,  but  inde- 
pendently of  no  value.  The  same  may  be  said  of  dryness  or  soreness  of 
the  mouth,  pharynx,  and  fauces.  Lastly,  general  adenitis,  which  occurs 
in  a  varying  degree  in  all  cases  of  syphilis  in  which  mercurialization  has 
not  been  effected  at  a  very  early  date,  is  a  strong  confirmatory  symptom, 
and  of  great  value  in  diagnosis  if  all  the  other  lesions  have  escaped  ob- 
servation. The  greatest  imiiortance  is  attached  to  induration  of  the 
epitrochlear,  and  to  the  occipital  and  post-mastoid  glands.  The  fonner 
can  scarcely  be  recognized  in  their  normal  state.  In  general  adenitis  a 
single  body,  feeling  like  a  small  bean  in  shape,  may  be  recognized  at  the 
inner  aspect  of  the  arm  just  above  the  elbow,  where  it  lies  superficial, 
and  internal  to  the  basUic  vein.  When  any  inflammatory  process  exists 
in  the  member  beyond  the  elbow,  the  enlarged  gland  possesses  no  spe- 
cific diagnostic  value.  In  like  manner  lesions  of  the  scalp,  face,  or 
mouth  may  cause  enlargement  of  the  occipital  or  mastoid  lymphatic 
glands. 

A  diagnosis  of  syphilis  in  the  tertiary  period  must  depend  ujjon  a 
careful  study  of  the  history  of  the  case  and  the  presence  of  one  or  more 
of  the  lesions  which  belong  to  this  stage,  and  which  have  been  fully  de- 
scribed. 

Prognosis. — A  favorable  prognosis  in  syphilis  will  depend  upon — 1, 
the  physical  condition  of  the  individual  affected  at  the  time  of  inocula- 
tion ;  2,  the  recognition  of  the  disease  within  the  first  two  or  three 
months  after  the  appearance  of  the  ulcer ;  3,  the  faithful  and  energetic 
co-operation  of  the  physician  and  patient  in  carrying  out  the  measures 
to  be  given. 

That  syphilis  is  a  curable  disease  there  can  be  no  doubt.  Under 
favorable  conditions  the  symptoms  disappear,  leaving  little  or  no  trace 
of  the  infection.  In  common  with  all  diseases,  its  severe  or  fatal  results 
are  seen  in  patients  with  an  inherited  or  acquired  dyscrasia,  and  in  those 
whose  nutrition  is  seriously  impaired.  Even  in  the  worst  class  of  cases 
the  prognosis  is  not  wholly  unfavorable  if  projper  treatment  is  instituted 
and  maintained. 

The  recognition  of  the  disease  and  the  institution  of  treatment  at  the 
time  of,  or  immediately  after,  the  appearance  of  the  eruption,  is  impor- 


730  A  TEXT-BOOK  ON   SURGERY. 

tant  in  securing  a  favorable  result ;  for,  if  this  is  done,  the  violence  of 
the  infection  may  be  modified  and  the  deeper  lesions  rendered  less  severe. 

Treatment. — The  treatment  of  syphilis  is  divided  into — 1,  measures 
which  tend  to  destroy  the  potency  of  the  virus  and  aid  in  absorption  of 
the  inflammatory  products  of  this  disease  ;  and,  2,  those  which  tend  to 
improve  the  nutrition  of  the  tissues.  Both  are  essential  to  the  successful 
management  of  this  formidable  afl'ection. 

To  the  former  belong  the  preparations  of  mercury  and  iodine  in  com- 
bination with  potassium  ;  to  the  latter  tonics,  the  careful  regulation  of 
the  habits  of  living,  nutritious  diet,  and  healthful  and  moderate  exercise. 

Nothing  is  more  satisfactorily  demonstrated  in  scientific  medicine 
than  the  power  of  mercury  to  neutralize  and  destroy  the  virus  of  syphi- 
lis. Its  administration  should  usually  begin  with  the  positive  recog- 
nition of  the  disease  at  the  appearance  of  the  eruption  (usually  about  the 
sixth  or  ninth  week).  It  is  always  advisable  to  wait  until  the  diagnosis 
is  assured,  rather  than  to  begin  treatment  with  the  recognition  of  the 
sore  or  bubo.  It  has  been  stated  that  these  symptoms  are  often  not 
reliable,  while  the  early  cutaneous  and  mucous  lesions  are  practically 
pathognomonic.  The  greatest  objection  to  the  early  institution  of  treat- 
ment is  the  doubt  which  may  be  left  in  the  mind  of  both  physician  and 
patient  of  the  correctness  of  the  diagnosis  by  the  early  disappearance  of 
the  initial  lesion  and  the  local  adenitis.  The  individual  affected,  as  well 
as  the  practitioner,  is  too  often  lulled  into  a  sense  of  security  by  the 
rapid  disappearance  of  the  early  symi)toms  ;  treatment  is  either  discon- 
tinued or  carelessly  carried  out  until,  after  several  weeks  or  months,  it  is 
discovered  that  the  disease  has  taken  a  firm  hold  upon  the  tissues. 

Commencing  with  this  date,  the  management  of  a  case  of  syphilis 
should  be  carried  on  for  a  period  of  two  years. 

It  is  of  the  utmost  importance  that  the  person  affected  should  be  im- 
pressed with  the  gravity  of  the  situation  and  the  certainty  of  disaster  if 
the  rules  laid  down  by  the  medical  adviser  are  not  strictly  obeyed.  With 
the  proviso  of  obedience,  the  prognosis  should  be  as  encouraging  as  pos- 
sible. Responsibility  for  the  result  of  treatment  in  this  disease  should 
not  be  assumed  unless  the  patient  consents  to  keep  himself  under  ob- 
servation for  the  period  above  given.  All  excesses  should  be  prohibited. 
The  use  of  tobacco  should  not  be  permitted.  Alcohol  in  any  shape  is 
scarcely  allowable.  In  certain  cases,  where  digestion  and  assimilation 
are  impaired,  a  small  quantity  of  whisky,  claret,  or  sherry  may  be  taken 
with  the  heaviest  daily  meal.  Sexual  indulgence,  if  from  no  other  than 
humanitarian  motives,  should  cease  for  at  least  a  year  from  the  appear- 
ance of  the  initial  lesion.  The  child  of  parents,  either  of  whom  is  within 
the  first  year  of  syphilitic  inoculation,  becomes  the  victim  of  a  dyscrasia 
which,  if  not  fatal  to  life,  is  fatal  to  the  perfect  usefulness  of  its  pos- 
sessor. 

In  addition  to  the  danger  of  direct  inoculation  during  the  prevalence 
of  the  chancre,  is  that  of  infection  to  the  mother  from  the  foetus  in  utero 
or  the  child  in  the  act  of  parturition.  A  patient  under  treatment  for 
syphilis  should  retire  early  and  at  a  regular  hour,  avoid  excessive  use 


TREATMENT   OF   SYPHILIS.  731 

of  tlie  eyes,  especially  at  night,  sudden  changes  in  temperature,  and  all 
articles  of  diet  which  are  not  readily  digestible. 

Of  the  preparations  of  mercury,  preference  should  be  given  to  the 
protoiodide.  It  is  conveniently  administered  in  pills  of  one-quarter  grain 
each.  To  begin  with,  one  of  these  pills  should  be  given  three  times  a 
day  one  hour  after  eating.  The  indications  for  a  diminution  in  the  quan- 
tity are  pain  of  a  cramp-like  nature  in  the  stomach  or  bowels,  with  or 
without  diarrhoea,  and  the  occurrence  of  salivation.  If  diarrhoea  results, 
it  will  be  advisable  to  administer  about  one-quarter  grain  of  opium  with 
each  pUl  of  protoiodide,  or  to  reduce  the  daily  number  of  the  pills. 
Under  such  conditions,  inunctions  with  mercurial  ointment  are  of  great 
value.  Salivation  may  be  guarded  against  by  careful  observation  of  the 
gums.  At  the  earliest  indications  of  tenderness  felt  when  the  teeth  are 
firmly  pressed  together,  or  when  direct  pressure  is  made  upon  the  alve- 
olus, the  dose  should  be  diminished,  or,  if  necessary,  discontinued  for  a 
few  days. 

It  will  usually  suffice  to  administer  one-quarter  grain  three  times  a 
day  for  the  first  month,  and  at  the  expiration  of  this  time  to  increase  the 
daily  quantity  to  gr.  j.  It  will  rarely  be  necessary  to  give  more  than 
this  quantity,  although  in  some  cases  the  full  beneficial  effects  of  the 
remedy  may  not  be  realized  until  a  larger  daily  dose  is  given.  The  mer- 
cury should  be  continued  without  interruption — excepting  for  the  reasons 
Just  given — for  the  first  six  months  after  commencing  the  treatment.  At 
the  expiration  of  this  period  it  is  a  good  plan  to  discontinue  the  proto- 
iodide for  two  weeks,  and  then  administer  the  iodide  of  potassium  in 
doses  of  grs.  x-xx  three  times  a  day  for  one  month.  This  should  in 
time  be  stopped,  and  the  pills  resorted  to  for  a  period  of  two  months, 
and  so  on,  alternating  these  two  remedies  to  the  end  of  the  first  year  of 
treatment.  For  the  first  six  months  of  the  second  year  the  alternation 
should  be  equal — i.  e.,  one  month  of  the  potassium  salt,  and  the  next 
the  protoiodide.  For  the  last  six  months  of  treatment  a  greater  propor- 
tion of  the  iodide  of  potassium  should  be  given. 

In  addition  to  the  foregoing  it  is  of  great  importance  that  tonics 
should  be  administered  from  the  commencement  of  the  disease,  and 
especially  in  delicate  patients.  In  carrying  out  this  part  of  the  treat- 
ment much  better  results  will  be  obtained  in  the  alternate  exhibition  of 
several  tonics  rather  than  in  the  continued  use  of  a  single  remedy.  A 
preparation  of  iron,  quinia,  and  strychnia  on  one  day,  given  in  the  proper 
dose  immediately  after  each  meal ;  an  emulsion  of  cod-liver  oil  with  the 
hypophosphites  of  lime  and  soda,  each  gr.  j  to  the  tablespoonf  nl  on  the 
next  day  ;  and  tincture  of  the  chloride  of  iron  on  the  third  day,  will  be 
found  a  convenient  and  useful  method  of  rotation. 

When  protoiodide  of  mercury  can  not  be  obtained,  the  biniodide,  in 
doses  of  gr.  ^  to  -j^,  or  chloride  of  mercury  (corrosive  sublimate),  gr. 
a'l)   i\  •  A 1  ^^y  be  substituted. 

If,  for  any  reasons,  mercurial  inunctions  become  necessary,  proceed 
as  follows  :  Take  about  a  teaspoonful  of  mercurial  ointment  and  rub  it 
well  into  the  skin  of  the  groin  and  under  the  arms.     Or  spread  the  oint- 


732  A  TEXT-BOOK   ON   SURGERY. 

ment  on  lint  and  apply  it  to  these  parts,  holding  it  in  place  by  lightly 
fitting  clothes  or  bandages.  It  should  be  nsed  only  at  night,  and  re- 
moved upon  rising  by  washing  with  warm  water  and  soap. 

The  hypodermic  injection  of  corrosive  sublimate  in  the  treatment  of 
syphilis  is  objectionable  on  account  of  the  annoyance  produced  by  the 
insertion  of  the  solution  beneath  the  integument.  It  is  an  unnecessary 
practice,  for  the  best  results  can  be  obtained  from  the  internal  adminis- 
tration of  the  protoiodide. 

In  the  treatment  of  the  tertiary  lesions  of  syphilis,  practically  the 
same  rule  of  practice  should  be  adopted  as  just  given  for  the  second 
year  following  the  appearance  of  the  initial  lesion.  The  employment  of 
iodide  of  potassium  in  full  doses  hastens  the  absorption  of  the  inflamma- 
tory products  of  this  stage,  while  the  jjrotoiodide  destroys  the  potency 
of  the  virus.  Both  remedies  should  be  administered  in  doses  as  large 
as  can  be  borne  without  interfering  with  the  fimctions  of  the  digestive 
organs  or  producing  any  serious  constitutional  disturbances. 

Inherited  SypJiilis. — The  foetus  may  become  syphilitic  from  a  syphi- 
litic father  or  mother.  If  pregnancy  occurs  within  the  first  year,  and 
especially  in  the  first  six  months  of  the  disease  in  the  mother,  the  child 
becomes  inoculated,  either  dying  in  utero,  or,  if  carried  to  term,  usually 
perishes  within  a  few  weeks  after  its  birth.  If,  however-,  the  disease  is 
recognized  and  proper  treatment  instituted,  a  more  favorable  prognosis 
may  be  made. 

In  the  second  year  after  infection,  if  properly  treated,  a  mother  may 
bear  a  non-syiDhilitic  child,  although  the  chances  are  against  complete 
immunity.  During  the  third  and  each  succeeding  year,  under  judicious 
management,  the  prognosis  is  still  more  favorable. 

A  female  patient  should  be  advised  of  the  great  danger  of  pregnancy 
within  the  two  years  immediately  following  inoculation.  When  she  has 
been  under  constant  and  proper  treatment  for  this  length  of  time,  and 
has  been  perfectly  free  from  symj)toms  for  one  year,  the  gravity  of  the 
danger  is  diminished.  If  she  has  not  been  treated,  she  should  under  no 
circumstances  be  made  liable  to  pregnancy.  In  case  such  a  woman 
should  become  pregnant,  she  should  be  treated  carefully  for  syphilis,  and 
in  this  way  the  infection  of  the  child  may  be  modified,  if  not  prevented. 

The  virus  of  syphilis  may  be  conveyed  by  the  sj)ermatic  elements, 
and  the  embryo  thus  become  inociilated."  The  prognosis  is  more  favor- 
able in  proportion  to  the  length  of  time  which  has  elapsed  after  the 
initial  lesion,  and  to  the  thoroughness  of  the  treatment  instituted.  A 
syphilitic  man  should  not  beget  a  child  within  two  years  after  the  initial 
sore,  nor  at  any  later  period  unless  thorough  treatment  has  been  insti- 
tuted and  one  year  has  elapsed  since  the  disappearance  of  all  symp- 
toms of  the  disease. 

*  As  heretofore  stated,  a  non-syphilitic  mother  may  be  inoculated  from  a  syphilitic  child  in 
the  act  of  parturition.  That  the  mother  is  also  subjected  to  the  influence  of  this  virus  from 
carrying  the  offspring  of  a  syphilitic  father  is  proved  by  Colles's  Imo,  which  is,  that  a  previously 
healthy  mother  of  such  a  child  can  nurse  it  without  danger  of  chancre  of  the  nipple  and  syphi- 
litic infection,  while  a  non-syphilitic  nurse  will  become  inoculated. 


INHERITED    SYPHILIS.  733 

Symptoms. — The  symiDtoms  of  specific  infection  in  the  child  manifest 
themselves  usually  within  the  first  eight  or  twelve  weeks  after  birth.  Oc- 
casionally the  disease  is  latent,  and  the  symptoms  do  not  appear  until 
a  variable  period  has  elapsed.  Even  puberty  may  be  reached  before  it  is 
evident.  Excepting  the  chancre,  the  local  lymphangitis  and  adenitis,  the 
evolution  of  the  symptoms  of  inherited  syphilis  is  not  unlike  those  of  the 
acquii'ed  form.     The  lesions  are  cutaneous,  mucous,  and  visceral. 

The  macular  or  papular  syjDhilide  occurs  in  most  cases,  and  may  be 
distributed  over  the  general  surface  or  confined  to  certain  limits.  It  is 
usually  first  seen  upon  the  abdomen,  and  from  this  starting-point  it  be- 
comes more  or  less  T\idely  distributed.  At  the  muco-cutaneous  margins, 
and  in  the  folds  of  the  skin  where  irritation  is  greater  and  moistiire 
exists,  condylomata  are  not  infrequent,  and  are  often  persistent.  Vas- 
cular, pustular,  and  tubercular  syphilides  occur  in  a  certain  proportion 
of  cases.  The  tubercular  form  is  rare.  The  pustular  form  (syphilitic 
pemphigus)  indicates  a  low  order  of  tissue  vitality,  and  justifies  an  un- 
favorable prognosis. 

Lesions  of  the  mucous  surfaces  occur  either  before  or  -ndth  the  cuta- 
neous lesions.  Papules  and  excoriations  (mucous  patches)  are  found  in 
the  buccal  cavity,  on  the  tongue,  fauces,  and  pharynx.  Fissures  of  the 
lips  are  not  uncommon,  and  especially  in  the  angles  of  the  mouth.  The 
infection  of  the  mucous  membrane  of  the  nose  and  air-passages  leads  to 
the  distressing  coryza  and  cough  so  often  noticed  in  syphilitic  infants. 
Gummata  of  the  skin  and  of  all  organs  occur  in  the  same  manner  and 
with  the  same  pathological  significance  as  in  the  acquired  form. 

Treatment. — The  preparations  of  mercury  antagonize  the  virus  in  this 
as  in  the  acquired  form  of  syphilis.  The  careful  mercurialization  of  the 
mother  during  pregnancy  is  important  in  preventing  the  development  of 
the  disease  in  its  severer  forms.  Inunction  with  the  ointment  of  mer- 
cury should  be  first  faithfully  tried  in  the  treatment  of  syphilis  in  the 
newly-born.  One  drachm  of  mercury  to  one  ounce  of  lard  is  the  ]3ro- 
portion  recommended  by  Brodie.  This  is  spread  upon  a  soft  flannel  belt 
and  worn  continuously  around  the  patient's  waist.  The  ointment  should 
be  renewed  as  needed.  If  the  beneficial  efi'ects  of  the  mercury  are  not 
secured  by  this  method,  the  internal  administration  may  be  resorted  to, 
but  in  no  case  until  after  a  thorough  trial  of  the  inunctions.  The  bin- 
iodide  of  mercury,  in  doses  of  -^  grain,  in  combination  with  one- quar- 
ter grain  of  the  iodide  of  potassium,  is  advisable  to  begin  with.  The 
dose  may  be  carefully  increased  if  necessary.  The  nourishment  of  the 
child  should  be  most  carefully  attended  to,  and  it  should  have  the  bene- 
fit of  pure  air  and  comfortable  surroundings. 

Scrotum. —  Wounds  of  the  scrotum  should  be  treated  as  similar  le- 
sions elsewhere.  On  account  of  the  great  vascularity  of  the  tissues,  re- 
pair is  usually  rapid.  The  contractility  of  the  dartos  and  cremaster 
muscles  will  prevent  early  union  unless  the  stitches  are  closely  applied. 
If  the  testicle  is  protruded,  it  should  be  disinfected  ^vith  1-to-lOOOO  sub- 
limate, returned  to  its  normal  position,  and  the  cavity  of  the  tunica  vagi- 
nalis also  washed  out  with  the  sublimate  solution.    In  closing  the  wound 


734  A  TEXT-BOOK  ON  SURGERY. 

with  catgut  sutures,  the  edges  of  the  opening  in  the  tunica  should  be 
included.  A  small  bone  or  catgut  drain  should  be  inserted  into  the 
cavity  and  emerge  at  the  lower  angle  of  the  incision. 

Contusions  should  be  treated  by  rest  in  the  horizontal  posture,  cold 
applications  and  mechanical  support  beneath  the  posterior  aspect  of  the 
scrotum. 

(Edema  of  the  scrotum  occurs  with  general  anasarca  and  with  ascites. 
The  integument  is  tense,  pale,  and  doughy  ;  pits  upon  pressure,  and, 
after  puncture  with  the  hypodermic  needle,  a  clear,  watery  serum  es- 
capes. Besides  the  indications  for  constitutional  treatment  directed  to 
the  disease  proper,  puncture  with  the  lancet  in  several  points  will  tem- 
porarily relieve  the  tension  and  danger  of  gangrene. 

Eczema  and  other  cutaneous  lesions  of  the  scrotum  do  not  demand 
especial  consideration.  The  same  general  principles  of  treatment  apply 
with  equal  force  to  all  the  cutaneous  surface.  The  prognosis  is  unfavor- 
able on  account  of  the  irritation  to  which  this  organ  is  subjected  from 
friction  with  the  clothing  and  thighs,  and  especially  owing  to  the  peris- 
taltic movements  of  the  dartos  and  cremaster  muscle. 

Cysts,  due  chiefly  to  the  retention  of  sebum,  are  occasionally  seen  in 
the  scrotum.  They  are  usually  situated  near  the  raphe,  or  laterally  and 
posteriorly  upon  the  base  of  the  scrotum.  When  large  enough  to  cause 
inconvenience,  incision  and  extirpation  of  the  sac  are  demanded. 

Erysipelas,  although  rare  in  this  portion  of  the  body,  is  met  with, 
and  is  often  obstinate  under  treatment.  Oangrene  is  one  of  the  chief 
dangers,  and  must  be  guarded  against  by  free  incision  as  soon  as  the 
tension  is  great.  PJilegmon  of  the  scrotum  should  be  treated  by  warm 
applications,  poultices,  etc.,  and  by  early  incisions  to  relieve  tension  and 
give  escape  to  septic  matter.  Free  drainage  and  sublimate  irrigation  are 
indicated. 

Elephantiasis  scroti,  comparatively  of  rare  occurrence  in  the  tem- 
perate and  colder  zones,  is  frequently  met  with  near  the  equator  ;  and  in 
some  of  the  West  Indies  and  the  islands  of  the  South  Pacific  Ocean  it 
occurs  with  great  frequency. 

The  pathology  of  this  form  of  connective-tissue  hyperplasia  has  been 
given.  The  cause  is  undoubtedly  one  of  prolonged  irritation.  The  only 
treatment  is  extirpation  with  the  knife.  No  fixed  rule  of  operating  can 
be  laid  down.  The  penis  is  at  times  buried  in  the  neoplasm,  and  should 
be  carefully  dissected  out.  The  incisions  should  be  made  so  as  to  give  a 
cutaneous  flap  in  front  and  behind  sufficiently  large  to  contain  the  testes 
and  cord  without  pressure  after  the  connective-tissue  new  formation  has 
been  dissected  out.  When  the  penis  is  included  in  the  new  growth,  the 
integument  should  be  saved,  to  cover  this  oi-gan.  If  this  can  not  be 
done,  flaps  may  be  turned  from  the  thighs  and  abdomen. 

The  haemorrhage  in  this  procedure  may  be  controlled  by  working  be- 
tween fixation-forceps,  or  by  the  adjustment  of  an  elastic  tourniquet 
around  the  scrotum  near  its  attachment  to  the  perinseum. 

Angioma  of  the  scrotum  is  rare,  and  demands  treatment  similar  to 
that  advised  in  the  chapter  on  these  vascular  formations. 


HuEMATOMA— PERIORCHITIS  AND  PERISPERMATITIS.      735 

Epithelioma  is  more  frequently  seen  than  eitlier  of  the  foregoing 
neoplasms,  and  calls  for  immediate  excision. 

Fistula,  or  sinuses  of  the  scrotum,  may  be  caused  by  abscess  of  the 
tunica  vaginalis  testis,  or  by  any  lesion  of  the  testicle.  Abscess  of  the 
perineeum  or  urinary  fistula  may  also  cause  fistula  of  the  scrotum. 
Stony  concretions  are  occasionally  met  with  in  fistulse  of  the  scrotum 
through  which  the  urine  makes  its  escape. 

The  treatment  should  be  directed  to  a  relief  of  the  cause  of  the  fis- 
tulous tracks.  If  this  is  accomplished,  the  sinuses  should  be  laid  open 
and  allowed  to  close  by  granulation. 

Hcematoma. — Extravasation  of  blood  may  occur  either  in  the  tunica 
funiculi,  in  the  tunica  vaginalis  testis,  or  in  both.  In  the  former  it  may 
be  diffuse  or  circumscribed.  It  is  usually  diffuse,  the  extravasation  ex- 
tending from  the  abdominal  opening  to  the  epididymis.  When  only  a 
portion  of  the  sheath  is  involved,  tbe  ha^matoma  is  generally  confined 
to  the  upper  segment. 

The  chief  causes  of  extravasation  are  rupture  of  one  or  more  vessels 
by  direct  traumatism,  or  by  over-distention  from  prolonged  strain,  which 
retards  the  return  circulation,  causing  rupture  of  a  vein. 

Hgematoma  of  the  tunica  vaginalis  testis  is  rare,  except  as  a  compli- 
cation of  chronic  periorcMtis  serosa  (hydrocele)  or  direct  violence. 

The  diagnosis  of  hgematoma  in  either  of  these  positions  depends  upon 
its  sudden  development,  the  tendency  to  enlarge  j)rogressively,  and  pain 
from  the  sudden  distention.  The  tumor  is  not  translucent.  The  exact 
nature  may  be  determined  by  aspiration. 

Serous  effusion  (hydrocele)  into  the  sheath  of  the  cord  or  testis  i^ro- 
gresses  slowly  and  painlessly.  The  tumor  is  translucent.  Exploration 
with  the  hypodermic  needle  and  syringe  is  a  safe,  painless,  and  positive 
means  of  diagnosis. 

Hernia  may  be  eliminated  by  a  consideration  of  the  history  of  the 
case  and  the  absence  of  impulse  in  the  tumor  upon  coughing. 

Treatment. — Hsematocele  maybe  treated  by  the  expectant  method,  or 
by  surgical  interference. 

Simple  and  limited  extravasation  requires  rest  in  the  dorsal  decu- 
bitus, and  the  ice-bag  locally.  After  the  haemorrhage  is  arrested,  absorp- 
tion may  be  expedited  by  judicious  and  well-applied  pressure  by  strap- 
ping. When  the  extravasation  is  extensive,  an  incision  should  be  made 
under  strict  antisepsis,  the  clot  turned  out,  the  bleeding-point  ligated, 
drainage  secured,  and  the  wound  closed.  Death  has  followed  in  some 
instances  where  operative  procedure  has  been  too  long  delayed. 

PeriorcMtis  and  Perispermatitis. — Inflammation  of  the  serous  in- 
vestments of  the  spermatic  cord  and  testicle  may  be  circumscribed  or 
diffuse.  An  inflammation  commencing  from  a  lesion  of  the  external  or 
scrotal  layer  usually  involves  the  entire  sac,  as  does  the  similar  process 
beginning  on  the  visceral  reflection  of  the  tunica. 

Perispermatitis  may  be  acute  or  chronic.  A  type  of  the  acute  in- 
flammation is  seen  in  severe  forms  of  epididymitis,  or  as  the  result  of 
direct  violence.     The  transudation  of  serum  may  be  limited,  and,  as  in 


736 


A  TEXT-BOOK   ON  SUKGERT. 


pleurisy,  adhesions  may  occur  with  obliteration  of  the  sac,  or  suppura- 
tion may  ensue ;  or,  passing  into  a  subacute  and  chronic  stage,  a  condi- 
tion of  true  hydrocele  of  the  cord  ensues  {perisperviatitis  clironica 
serosa). 

Effusion  into  the  sheath  of  the  cord  may  communicate  with  the  cavity 
of  the  tunica  vaginalis  testis  (Fig.  654),  or  with  the  peritoneal  cavity 


Fig.  054. — Hydrocele  of  the 
cord  communicating  with 
the  tunica  vaginalis  testis. 
The  instrument  is  passed 
through  the  membrane 
which  separates  the  fluid 
from  the  peritonaeum,  a, 
Testis.    (After  Liuhart. ) 


Fig.  655.— c,  Hydro- 
cele of  the  cord  com- 
municating with  the 
peritoneal  cavitv.  a, 
Testis.    (After  "Lin- 

.  hart.) 


Fig.  656.— Encysted 
hydrocele  of  the 
cord. 


Fig.  657. — Hydrocele 
of  the  tunica  vagi- 
nalis testis.  (Alter 
Linhait.) 


It  is 


(congenital  hydrocele)  (Fig.  655),  but  these  conditions  are  rare, 
usually  coniined  to  the  tunica  funiculi  (Fig.  656). 

The  diagnosis  of  this  form  of  hydrocele  rests  upon  the  recognition 
of  a  fluctuating  tumor  in  the  line  of  the  cord,  and  the  exclusion  of  hsema- 
tocele,  varicocele,  and  hernia. 

The  symptoms  of  hsematocele  have  just  been  given.  The  peculiar 
feel  of  a  varicocele,  so  well  compared  to  the  sensation  felt  in  grasping  a 
mass  of  earth-worms  between  the  fingers,  can  scarcely  be  mistaken.  If 
the  recumbent  posture  is  assumed,  the  varicose  veins  are  emptied  and 
the  tumor  disappears.  This  can  not  occur  in  cyst  of  the  cord.  A  hernial 
tumor  gives  the  characteristic  impulse  upon  coughing  ;  a  cyst  does  not. 
A  reducible  hernia  will  disappear  in  the  recumbent  posture,  and  if,  when 
reduced,  the  finger  is  pressed  into  the  internal  ring,  it  will  not  recur, 
while,  despite  this  precaution,  a  varicocele  will  reappear.  Exploration 
with  a  hypodermic  needle  will  disclose  the  character  of  the  contents. 
The  treatment  of  hydrocele  of  the  spermatic  cord  is  practically  the  same 
as  that  for  hydrocele  of  the  tunica  vaginalis  testis. 

PeriorcMtis  may  also  be  acute  or  chronic.  In  acute  inflammation  the 
quantity  of  serous  transudation  may  be  large  or  small.  When  the  in- 
flammatory process  is  acute,  and  the  transudation  of  serum  so  limited 
that  the  opposing  surfaces  of  the  two  walls  are  not  kept  apart,  adhe- 
sions may  occur,  with  partial  or  complete  obliteration  of  the  sac. 

The  causes  include  all  lesions  of  the  scrotum,  the  testicle,  and  epi- 
didymis, the  process  naturally  extending  to  the  delicate  lining  membrane. 


PEEIOECHITIS. 


7S1 


Chronic  epididymitis  and  orcMtis  should  rank  as  first  in  the  fetiology 
of  hydrocele.  The  interference  of  the  return  circulation  here  will  pro- 
duce the  transudation  of  iiuid  in  the  same  way  as  ascites  occurs  in  cir- 
rhosis of  the  liver.  In  like  manner  varicosities  in  the  veins  of  the  sper- 
matic plexus  may  induce  hydrocele.  The  pathological  changes  consist 
in  a  general  thickening  of  the  visceral  and  parietal  layers  of  the  tunica, 
due  to  the  development  of  connective-tissue  elements  in  which  new  ves- 
sels are  formed. 

iN'ot  infrequently  little  pearl-like  bodies  are  seen  attached  to  the  vis- 
ceral  surface  of  the  thickened  tunica,  or  they  may  be  found  floating  free 
in  the  fluid  of  the  sac.  They  are  made  up  of  connective-tissue  and  flat- 
tened epithelial  elements.  Occasionally  they  undergo  the  calcareons 
metamorphosis.  The  sac  of  a  hydrocele  of  the  tunica  vaginalis  testis  is 
almost  always  unilocular  (Fig.  6.58 ;,  but  in  rare  instances  it  is  bilocular, 
with  a  naiTow  opening  of  communication  between  the  sacs  (Fig.  659). 
The  dividing  septum  is  made  up  of  the  products  of  inflammation. 


Fig.  65S.— r-:-il  :  r:n     :'  I 
(After  Kocher.; 


Fk.  559.— BUoouIar  h-drr-ieie.  Tc,  Parietal 
laver  of  ruiii:-a.  .>.  S;  eniiatic  cord.  3'A, 
Epididymis.  JI.  Tekis.  B.  Cavity  of 
diTerticulnm.  Tt,  Carity  of  tie  tnnica 
va^tnalis  propritis.  Zz.  InilaniiEatory 
new  formation  between  the  visceral  ani 
parietal  layers.    (After  Kocher.  i 


The  fluid  of  hydrocele  is  amber  in  color,  or,  if  blood  has  been  ex- 
travasated  and  mixed  vrith  it,  it  may  be  brownish-black  or  red.  Under 
the  microscope  it  is  seen  to  contain  compound  granular  corpuscles,  leu- 
cocytes, swollen  endothelia,  and  at  times  crystals  of  cholesterin  and  red- 
blood  disks. 

Symptoms. — Hydrocele  of  the  tunica  vaginalis  testis  is  usaally  single 
— at  times  double.  la  shape  the  tumor  is  usually  pyriform  or  oval,  with 
the  largest  diameter  of  the  swelling  below.  It  may,  however,  assume  a 
conical  shape,  with  the  apex  downward,  as  shown  in  Fig.  660.  The  his- 
tory is  generally  that  of  a  slow  and  painless  swelling,  first  noticed  in 
the  lower  portion  of  the  scrotum,  and  gradually  extending  upward.  In 
size  it  may  vary  from  a  mass  having  a  long  diameter  of  an  inch  or  two, 
47 


738 


A  TEXT-BOOK  ON  SURGERY. 


to  as  mucli  as  ten  or  twelve  inches.  In  recent  cases  the  walls  are  thin, 
fluctuation  is  easily  made  out,  and  the  testicle  may  be  recognized  in  the 
lower  posterior  portion  of  the  swelling.  In  old  cases  the  walls  may 
measure  half  an  inch  or  more  in  thickness,  and  are  so  tense  and  in- 
elastic that  to  the  touch  the  tumor  seems  wholly  solid.  The  differentia- 
tion includes  hydrocele  of  the 
cord,  encysted  hydrocele  of  the 
testis,  hernia,  varicocele,  and  va- 
rious neoplasms  or  swellings  of 
the  testis  and  epididymis. 

Hydrocele  of  the  cord  is  ob- 
long or  spherical  in  shape,  usu- 
ally of  small  size,  and  gives  a  his- ' 
tory  of  a  swelling  commencing 
above  the  testicle,  which  organ 
can  be  made  out  by  palpation  be- 
low the  tumor.  Encysted  hydro- 
cele of  the  testicle  can  only  defi- 
nitely be  made  out  by  puncture 
with  the  aspirator-needle  and  ex- 
amination of  the  contents  with 
the  microscope.  The  presence  of 
the  spermatozoa  will  determine 
the  encysted  character  of  the  tu- 
mor. In  hernia  the  swelling  be- 
gins at  the  inguinal  ring,  and 
travels  progressively  downward. 
If  reducible,  it  can  be  made  to 
disappear  by  assuming  the  dor- 
sal decubitus,  while  a  hydrocele 
would  be  lanaffected  by  this  ma- 
noeuvre. Percussion  upon  an  in- 
testinal hernia  will  yield  resonance,  while  that  upon  the  tumor  of  hydro- 
cele gives  dullness.  Omental  hernia  is  doughy  to  the  feel,  while  hydro- 
cele is  tense  and  resisting.  Varicocele  can  be  eliminated  by  the  peculiar 
impression  conveyed  to  the  fingers  when  the  worm -like  veins  are  grasped. 
The  solid  character  of  neoplasms  of  the  testis  or  epididymis  can  be 
recognized  by  palpation.  Of  most  importance,  however,  is  the  employ- 
ment of  the  exploring  aspirator,  which  safely  and  easily  demonstrates 
the  liquid  character  of  the  contents  of  hydrocele. 

Treatment. — The  cure  of  hydrocele  is  effected  in  almost  all  cases  by 
operative  interference.  The  transudation  of  serum  into  the  cavity  of 
the  tunica  vaginalis  testis,  symptomatic  of  specific  disease,  or  any 
acute  local  affection,  may  disappear  by  absorption  under  proper  medi- 
cal treatment,  or  after  the  disappearance  of  the  acute  trouble.  These 
cases  are,  however,  exceptional  ;  and,  if  absorption  does  not  occur 
within  the  first  few  weeks  of  the  history  of  the  affection,  operation  is 
demanded. 


I.  660. — Double  hydrocele  of  the  tunica  vaginalis 
testis.  (From  a  patient  operated  upon  at  Mount 
Sinai  Hospital.) 


PERIORCHITIS.  739 

The  operative  procedures  are  two  in  number — 1,  by  injection,  and  2, 
by  incision.  The  fonner  method  should  be  preferred  in  all  cases  of 
recent  formation,  in  which  there  is  not  great  thickening  of  the  walls, 
and  in  which  the  sac  is  not  very  large.  It  may  be  safe  to  include  in  this 
category  all  cases  in  which  the  long  diameter  of  the  tumor  is  not  more 
than  five  inches,  and  in  which  the  depth  of  tissue  between  the  integu- 
ment of  the  scrotum  and  the  cavity  of  the  sac  is  not  more  than  half  an 
inch.  If  this  procedure  fails,  it  should  be  repeated  once  or  twice  be- 
fore the  more  formidable  procedure  known  as  Volkmann's  operation  is 
undertaken. 

First  Method — Levis^s  Operation. — Shave  the  tumor  on  its  anterior 
aspect,  and  cleanse  the  integument  thoroughly.  Inject  from  v\,  x-xv  of 
a  4-per-cent  cocaine  solution  in  such  a  way  that  local  anaesthesia  will  be 
obtained  through  the  depth  of  the  wall  of  the  sac  throiighout  an  area  of 
half  an  inch  in  diameter.  Twenty  minims  of  pure  carbolic  acid  should 
now  be  placed  in  the  syringe,  and  a  long  needle  attached.  Place  the 
patient  upon  the  back,  separate  the  thighs,  have  a  pus-basin  convenient, 
support  the  tumor  with  the  left  hand,  making  the  parts  tense  by  press- 
ure ;  take  a  trocar-canula  in  the  right  hand,  firmly  seized  between  the 
thumb  and  finger  one  inch  from  the  point  (so  that  it  may  not  possibly 
be  thrust  in  farther  than  this  limit) ;  remember  that  the  testicle  is  be- 
hind and  below,  and  with  a  quick  and  accurate  thrust  carry  the  instru- 
ment through  the  anaesthetized  zone  into  the  cavity  of  the  sac.  The 
point  of  entrance  should  be  about  one  third  of  the  distance  from  the 
lower  portion  along  the  anterior  aspect  to  the  upper,  and  the  direction 
of  the  shaft  of  the  trocar  should  be  upward  and  somewhat  backward. 
Upon  removal  of  the  stylet  the  liqiiid  rapidly  escapes  through  the  can- 
ula,  any  remnant  being  forced  out  by  compression.  Care  must  be  taken 
not  to  shift  the  canula  from  its  first  position.  When  the  fluid  is  emptied, 
carry  the  hypodermic  needle  into  the  canula,  and  force  the  carbolic  acid 
into  the  sac  ;  withdraw  the  needle,  and  then  the  canula,  and  knead  the 
scrotum  and  sac  so  as  to  distribute  the  acid  over  the  entire  surface. 
This  operation  is  almost  without  pain.  In  some  instances  a  slight  sense 
of  faintness  is  experienced  Just  as  the  acid  is  injected.  The  patient 
should  be  kept  quiet  on  the  day  of  the  operation,  but  with  proper  sus- 
pension of  the  scrotum  he  may  be  allowed  to  move  about  after  twenty- 
four  hours.  On  the  day  following,  and  for  about  a  week  afterward,  the 
tumor  swells  up  as  if  it  were  refilling,  and  is  solid  or  doughy  to  the  feel. 
After  this  it  begins  to  decrease  imtil  the  sac  is  obliterated  and  a  per- 
manent cure  is  effected.  A  scrotal  wall  and  the  investing  serous  mem- 
brane of  the  testicle  which  is  once  thickened  becomes  somewhat  thinner 
after  the  cure  of  the  hydrocele,  but  never  entirely  resumes  its  natural 
thickness. 

Second  Method — Volkmann^s  Operation. — Shave  the  scrotum  and 
pubes,  narcotize  the  patient  with  ether,  and  over  the  anterior  middle 
line  of  the  side  affected  make  an  incision  varying  in  length  with  the  size 
of  the  tumor  and  the  thickness  of  the  wall.  Usually  an  incision  from 
two  to  four  inches  in  length  will  suffice.     Cut  directly  down  until  the 


740  A  TEXT-BOOK   ON  SURGERY. 

sac  is  reached,  and  incise  this  to  about  the  same  extent  as  for  the  wound 
in  the  integument,  allow  the  fluid  to  escape,  and,  with  a  good-sized  cat- 
gut continuoiis  suture,  stitch  the  cut  edge  of  the  parietal  layer  of  the 
tunica  vaginalis  testis  to  the  edge  of  the  wound  in  the  skin,  making  an 
opening  not  unlike  a  button-hole.  Irrigate  the  sac  with  l-to-3000  subli- 
mate solution,  and  insert  a  rubber  drainage-tube  into  the  iipper  and 
lower  portions  of  the  cavity,  and  apply  a  sublimate-gauze  dressing. 

In  all  antiseptic  dressings  about  the  penis  it  is  essential  to  isolate 
this  organ  so  that  the  urine  or  the  usual  unclean  condition  of  this  or- 
gan may  not  infect  the  wound.  To  do  this  after  the  drainage  is  secured 
and  the  first  gauze  is  placed  around  the  tubes  along  the  edges  of  the 
button-hole,  make  a  hole  in  all  the  layers  of  sublimate  gauze  and  the 
sheet  of  protective  large  enough  for  the  penis  to  pass  through  without 
constriction.  Lastly,  tuck  the  dressing  well  up  under  the  scrotum  close 
to  the  perinseum,  to  keep  the  gases  and  fecal  discharges  from  infecting 
the  wound.  This  operation  will  cure  any  case  of  hydrocele  which  will 
not  yield  to  the  more  conservative  procedure  of  Levis.  It  can  only  be 
dangerous  by  neglect  of  careful  drainage.  In  very  large  sacs  a  counter- 
opening  should  be  made  through  the  lower  portion.  Such  Avounds 
rarely  reqiiire  more  than  one  or  two  changes  in  the  dressings,  and  only 
then,  as  in  all  surgical  wounds,  when  the  discharge  soils  the  dressings, 
escapes  beyond  the  area  of  antisepsis,  and  becomes  offensive  by  decom- 
position, or  when  the  rise  in  temperature  indicates  the  presence  of  sep- 
tic absorption. 

Bone-drains  may  be  used  in  the  smaller  tumors,  but  rubber  gives  a 
better  guarantee  of  perfect  drainage. 

Suj)purating  periorchitis,  or  pus  in  the  cavity  of  the  tunica  vaginalis, 
may  be  treated  by  two  methods :  If  the  temperature  is  high,  the  sac 
painful,  and  the  scrotum  swollen,  the  indications  are  for  free  incision, 
irrigation,  and  drainage.  Under  less  threatening  conditions,  the  aspira- 
tor may  be  employed,  the  sac  emptied  and  repeatedly  injected  and  washed 
out  with  l-to-5000  sublimate  solution,  and  compression  applied  afterward. 
In  this  way  obliteration  of  the  sac  may  be  achieved,  as  in  the  treatment 
of  cold  abscesses. 

Varicocele. — Yaricosities  of  the  veins  of  the  spermatic  plexxxs  are  not 
uncommon.  Varicocele  is  chiefly  caused  by  gravity  and  the  mechanical 
interference  with  the  return  of  blood  through  the  spermatic  veins.  It 
occurs  with  greater  frequency  on  the  left  side,  where  the  vessels  are 
pressed  upon  by  the  sigmoid  flexure  of  the  colon  with  its  almost  constant 
weight  of  fecal  matter.  In  addition  to  this,  the  greater  length  of  the  left 
spermatic  vein,  which  enters  the  renal  vein  at  a  right  angle  to  its  axis, 
and  is  poorly  protected  by  valves,  are  causes  which  serve  to  produce 
varicosities  upon  this  side  more  frequently  than  in  the  right  plexus. 
Any  occupation  which  necessitates  the  erect  posture  is  apt  to  add  to  the- 
susceptibility  of  this  disease.  Hereditary  tendencies  must  be  considered 
in  its  fetiology,  for  frequently  members  of  a  family  through  several  gen- 
erations will  be  affected. 

The  earlier  symptoms  are  a  feeling  of  heaviness  or  dragging  down  on 


VARICOCELE. 


14:1 


the  side  affected,  with  the  appearance  of  a  small  swelling  in  the  line  of 
the  cord.  Pain  is  variable,  and  is  sometimes  referred  to  the  cord  or  to 
the  inguinal  region  or  down  the  leg.  The  testicle  hangs  lower  than 
natural,  and  along  the  cord  can  be  felt  a  network  of  turgid  veins  extend- 
ing from  the  epididymis  toward  the 
external  ring.  To  the  toiich  they  seem 
not  unlike  a  knot  of  earth-worms. 
The  swelling  is  apt  to  be  largest  at  the 
lower  extremity  (Fig.  661). 

The  diagnosis  is  not  difScult. 

The  swelling  of  inguinal  hernia  is 
spherical,  and,  when  composed  of  in- 
testine, it  is  resonant  on  percussion. 
If  the  hernia  is  reducible,  and  is  re- 
turned into  the  cavity  of  the  abdomen 
with  the  patient  in  the  recumbent 
posture,  and  if  the  index-finger  is  car- 
ried into  the  internal  ring  and  held 
there  while  the  patient  is  made  to 
stand  erect,  the  veins  will  again  refill 
and  demonstrate  the  varicocele,  while 
the  hernia  will  be  prevented  from  de- 
scending. Hsematoma,  or  hydrocele 
of  the  cord,  can  be  recognized  by  as- 
piration with  the  hypodermic  syringe. 

Treatment. — Very  few  cases  of  vari- 
cocele require  operative  interference. 
A  well-adjusted  suspensory  apparatus 
constantly  worn  while  in  the  erect  post- 
ure will  obviate  the  necessity  for  an 
operation  in  the  vast  majority  of  in- 
stances. This  bag  may  be  made  to  include  and  support  only  one  half 
the  scrotum  and  a  single  testicle,  or  the  double  elastic  apparatus  may 
be  employed.  When  no  palliative  measures  are  effectual,  operative  in- 
terference is  demanded.  The  procedures  are  two  in  number,  namely, 
subcutaneous  ligature  (Keyes),  or  incision  and  ligature  hy  the  open 
method.,  with  or  without  ablation  of  the  redundant  scrotum.  Of  these 
two  operations  the  latter  is  preferable.  It  is  an  open  operation,  radical, 
and  invariably  successful  when  properly  done. 

First  Method — Reyes's  Operation. — Shave  the  scrotum  and  pubes, 
and  thoroughly  wash  these  surfaces  with  ether  and  sublimate  solution. 
The  patient  is  made  to  stand  erect,  with  the  legs  separated,  in  order  to 
distend  the  veins.  In  cold  weather  it  may  be  necessary  to  have  him  sit 
in  a  tub  of  hot  water  to  induce  full  relaxation.  By  the  injection  of  co- 
caine, local  anfesthesia  should  be  obtained  in  the  parts  where  the  ligature 
is  to  be  inserted.     From  n  x-xx  of  a  4-per-cent  solution  will  suffice. 

The  ligature  should  be  of  Chinese  twisted  silk,  not  too  large,  but 
capable  of  bearing  all  the  strain  whicli  will  ordinarily  be  brought  against 


Fig.  661. — Varicosities  of  the  spermatic  plexus 
of  veins,  with  atrophy  of  the  testicle. 
(After  Kocher.) 


742  A  TEXT-BOOK   ON"  SURGERY. 

it.  This  should  be  thoroixghly  soalied  in  l-to-2000  sublimate  solution 
for  several  hours  before  it  is  to  be  used.  For  passing  the  ligature  around 
the  mass  of  veins,  Keyes's  needle  (Fig.  662)  should  be  preferred.  It  is 
better,  as  Avill  be  seen,  to  have  two  of  these  instruments.  If  these  can 
not  be  obtained,  the  long  needle  of  Peaslee,  or  an  ordinary  darning- 
needle,  may  be  substituted.     With  everything  in  readiness,  proceed  as 


Fig.  662.— Keyes's  v.iricoeele-needle. 

follows :  The  operator,  by  careful  manipulation,  finds  the  vas  deferens 
as  it  is  located  in  the  posterior  part  of  the  cord  near  the  level  of  the 
scrotal  attachment  to  the  peringeum,  separates  it  from  the  mass  of  veins, 
and,  by  tightly  pinching  the  scrotal  walls  between  the  thumb  and  finger 
of  the  left  hand,  holds  this  important  duct  behind  and  to  the  inner  side 
of  the  veins.  • 

The  vas  deferens  may  be  recognized  by  its  dense  and  leathery  feel. 
It  is,  as  a  rule,  smaller  than  the  veins,  but,  while  these  may  be  effaced 
by  pressure,  the  vas  deferens  is  so  thick  that  it  can  not  be  obliterated, 
but  mil  jump  from  between  the  thumb  and  finger  when  tightly  squeezed. 
Once  eliminated  and  secured  behind  the  veins,  pressure  should  not  be 
interrupted  until  the  threaded  needle  is  passed  entirely  through  both 
walls  of  the  scrotum  from  before  backward  between  the  vas  deferens  and 
the  plexus  of  veins.  If  two  needles -are  on  hand,  the  one  now  passed 
through  should  be  left  in  jposition,  and  the  pressure  with  the  thumb  and 
finger  of  the  left  hand  being  no  longer  needed,  this  hand  may  be  used 
to  facilitate  the  second  step  in  the  operation.  The  second  needle,  with- 
out being  threaded,  should  now  be  made  to  enter  by  the  side  of  and  in 
the  same  opening  with  the  first,  and  as  soon  as  the  point  is  well  within 
the  dartos — but  not  deep  enough  to  puncture  the  veins — it  should  be 
carefully  worked  between  the  veins  and  dartos,  around  the  mass  to  the 
outer  side,  and  made  to  emerge  behind  at  the  same  opening  with  the 
other  instrument.  The  thread  is  now  disengaged  from  the  first  needle 
and  carried  through  the  eye  of  the  second,  which,  upon  being  withdrawn, 
completes  the  circuit  of  the  ligature  around  the  mass.  It  should  now 
be  tied  slowly  and  securely.  The  single  knot  is  preferable,  since  the  fric- 
tion of  the  double  knot  is  so  great  that  the  thread  may  break  in  the 
effort  to  draw  it  tight  enough  to  constrict  the  veins  (an  accident  which 
has  twice  happened  to  myself).  The  first  needle  should  not  be  with- 
drawn until  the  ligature  is  secured,  since,  shoiild  the  thread  break,  the 
second  needle  will  alone  have  to  be  inserted.  As  the  first  loop  of  the 
knot  is  tightened,  the  mass  within  its  grasp  should  be  held  by  an  assist- 
ant to  prevent  its  slipping  before  the  second  loop  is  finished.  When 
completed,  the  ends  are  cut  close  to  the  hole  of  entrance,  and  the  walls  of 
the  scrotum  separated  when  the  knot  and  ends  disappear  inside  the  dar- 
tos. A  light  sublimate  dressing  is  required.  The  patient  should  remain 
in  bed  one  day,  and  keep  quiet  about  the  house  for  four  or  five  more. 


THE   VESrCUL^   SEMINALES. 


743 


Little  or  no  pain  is  experienced  after  the  operation,  and  none  in  its  per- 
formance, if  a  few  minims  of  cocaine  solution  are  injected  near  the  point 
where  the  needles  enter  and  emerge.  The  ligature  becomes  encapsuled 
and  remains  harmless.  Inflammation  and  suppuration  are  scarcely  pos- 
sible where  the  antiseptic  details  are  jDroperly  carried  out.  The  tissues 
around  and  below  the  thread  are  indurated  within  a  few  hours,  and  re- 
main so  for  a  number  of  weeks,  the  coagulated  blood  undergoing  gradual 
absorption.  Catgut  is  not  reliable  as  a  ligature  in  this  operation,  on 
account  of  the  danger  of  too  rapid  absorption.  In  one  case  I  failed  with 
this  material,  afterward  effecting  a  cure  with  silk,  which  was  employed 
at  the  suggestion  of  Prof.  Keyes. 

Second  Method — Ligature  througTi  an  Open  Wound. — Anesthetize 
the  patient,  shave  the  parts  thoroughly,  and  expose  the  cord  by  an  in- 
cision several  inches  in  length  made  along  its  anterior  lateral  aspect 
from  the  external  inguinal  opening  downward.  Search  for  the  vas 
deferens,  which  can  be  easily  recognized,  after  the  skin  is  turned  aside, 
by  its  cartilaginous  feel ;  have  this  held  to  one  side,  and,  with  an  aneu- 
rism-needle armed  with  good-sized  catgut  ligatures,  tie  the  veins  sepa- 
rately in  three  or  four  different  places,  beginning  at  the  external  ingui- 
nal ring  and  ending  at  the  epididymis.  The  wound  should  be  closed 
with  catgut,  and  a  bone  drain  inserted. 

In  a  majority  of  cases  the  scrotum  will  be  so  elongated  that  am- 
putation of  the  redundant  portion  is  necessitated  after  the  veins 
are  tied. 

In  performing  this  operation  Henry's  or  King's  clamp  will  be  found 
of  great  service  ;   which,  if  properly  adjusted,  allows  the  amputation 


Fig.  G63. — Henry's  scrotal  clamp, 


to  be  made  and  the  edges  of  the  wound  sewed  with  close  sUk  sutures 
while  the  instrument  is  in  position,  thus  avoiding  all  ligemorrhage  and 
the  necessity  for  a  single  ligature  in  the  line  of  amputation.  If  this 
instrument  can  not  be  obtained,  the  testicles  may  be  pushed  up  into 
the  rings  and  the  amputation  effected  by  cutting  across  the  scrotum 
below  the  fingers  of  an  assistant  which,  by  grasping  the  tissiies  ]Droperly, 
control  all  bleeding. 

The  Vesicidce  Seminales  and  Va.s  Deferens. — The  seminal  vesicles 
are  occasionally  wanting,  from  failure  of  development,  or  from  atrophy 
as  a  result  of  inflammation.  Wounds  of  these  organs  are  rare.  If  in- 
cised or  punctured,  temporary  fistula  may  result,  with  subsequent  atro- 


744  A  TEXT-BOOK  ON  SURGERY. 

phy.  Inflammation  of  the  vesiculse  seminales  occurs  by  extension  from 
the  urethra  or  from  the  epididymis  and  vas  deferens,  or  with  prostatitis 
or  proctitis.  Occlusion  of  the  ejaciilatory  duct  induces  over-distention  of 
these  organs.     Several  cases  of  calculus  of  the  duct  have  been  recorded. 

The  diagnosis  in  dilatation,  hypertrophy,  or  inflammation  of  these 
cysts  depends  upon  careful  rectal  exi^loration. 

The  vas  deferens  is  more  or  less  involved  in  all  inflammatory  pro- 
cesses which  occur  in  the  epididymis.  It  is  also  subject  to  invasion  by 
inflammation  from  the  urethra  and  prostate.  Tuberculosis  of  this  ves- 
sel may  follow  tuberculosis  of  the  testes  and  epididymis.  Lesions  of  this 
organ  require  no  especial  consideration. 

Epididymis. — Neoplasms  of  the  sheath  of  the  spermatic  cord  are 
rare.  In  his  excellent  monograph,  Kocher  mentions  isolated  cases  of 
lipoma,  fibroma,  or  myxofibroma  and  sarcoma. 

Epididymitis  results  occasionally  from  direct  violence,  but  is  chiefly 
due  to  urethritis  and  the  extension  of  the  inflammatory  process  along 
the  vas  deferens.  Metastatic  or  "sympathetic"  inflammation  of  this 
organ  is  very  rare.  It  may  be  acute  or  chronic.  The  inflammatory  pro- 
cess may  be  confined  to  the  epididymis  or  invade  the  testicle.  Acute 
epididymitis  always  involves  the  tunica  vaginalis  (with  which  it  is  in 
contact),  and  very  frequently  the  testicle.  Specific  urethritis  stands  first 
in  order  in  the  causation  of  epididymitis.  The  introduction  of  a  sound 
or  catheter,  the  lodgment  of  a  calculus  in  the  ui^ethra  or  prostate,  strict- 
ure, cystitis,  and  prostatitis  may  also  cause  this  disease. 

The  symptoms  of  acute  epididymitis  are  a  sense  of  uneasiness  or 
pain,  varying  in  intensity  in  the  organ  afPected,  or  in  the  cord  or  groin. 
It  is  increased  by  pi-essure,  when  the  erect  posture  is  assumed,  or  in 
walking. 

In  severe  cases  a  chill  or  rigors  occur,  followed  by  a  marked  rise  in 
temjierature.  Upon  inspection  there  will  be  more  or  less  induration 
along  the  posterior  border  of  the  testicle,  with  heat,  redness,  and  ten- 
sion. The  testicle  is  more  or  less  enlarged,  and  very  frequently  there  is 
a  serous  transudation  into  the  cavity  of  the  tunica  vaginalis  testis. 

The  pathological  changes  consist  chiefly  of  hypersemia  and  infiltra- 
tion of  the  connective-tissue  framework  with  embryonic  cells.  The 
epithelial  lining  membrane  is  also  thickened  and  injected. 

The  diagnosis  depends  upon  the  symptoms  above  given.  The  prog- 
nosis is  usually  favorable.  One  attack,  however,  predisposes  to  another. 
In  some  instances  occlusion  of  the  efferent  apparatus  results  from  con- 
traction of  the  products  of  inflammation,  and  sterility  follows.  Sper- 
matic fistula  is  the  rule  in  these  cases. 

The  treatment  consists  in  the  administration  of  saline  laxatives  in 
order  to  empty  the  alimentary  canal.  The  patient  should  be  placed 
upon  his  back,  and  the  inflamed  organ  supported  by  either  a  three-cor- 
nered pillow  between  the  thighs,  or  a  towel  pinned  around  both  thighs 
just  below  the  base  of  the  scrotum.  Upon  this  a  small  bladder  filled 
with  crushed  ice  may  be  placed,  and  the  inflamed  organ  allowed  to  rest 
upon  it.     If  cold  is  not  grateful,  warm  cloths  or  a  poultice  may  be  sub- 


THE   TESTICLE.  745 

stituted.  The  application  of  from  three  to  six  leeches  will  at  times 
relieve  the  local  congestion. 

Usually  rest  in  bed  will  alone  suffice  to  effect  a  cure.  In  some  in- 
stances operative  interference  is  indicated.  When  the  tension  is  great 
and  the  pain  extreme,  the  happiest  results  will  follow  multiple  puncture. 
Proceed  as  follows  :  Take  a  sharp,  narrow  knife  and  push  it  through  a 
cork  until  from  a  quarter  to  half  an  inch  of  the  point  is  exposed.  Hold 
the  organ  in  the  left  hand  so  as  to  expose  the  posterior  aspect  of  the 
epididymis  and  make  the  skin  fairly  tense,  and  plunge  the  blade  in  up  to 
the  cork  in  from  two  to  six  or  ten  points  along  the  most  swollen  and  in- 
durated portions  of  the  tumor.  A  free  escape  of  dark  blood  follows. 
The  operation  is  very  painful,  b^^t  the  relief  is  marked  and  immediate. 
A  suspensory  bandage  should  be  worn  during  convalescence.  The  treat- 
ment of  chronic  epididymitis  will  be  considered  with  that  of  orchitis. 

Tlie  Testicle. — Wounds  of  this  organ  do  not  demand  especial  consid- 
eration. Hernia  of  the  tubules  not  infrequently  occurs  from  incision  or 
puncture  of  the  tunica  albuginea.  Reduction  is  pi-actically  impossible. 
The  protruded  portion  should  be  tied  off  with  a  catgut  ligature,  the  ex- 
cess of  substance  beyond  the  thread  cut  off,  and  the  organ  returned  to 
the  normal  position. 

Inflammation  of  the  testis  (orchitis)  may  result  from  direct  violence, 
from  the  extension  of  an  epididymitis,  or  from  metastasis.  Orchitis  is 
frequently  met  with  as  a  symptom  of  "mumps,"  but  the  relation  between 
these  two  processes  is  not  understood. 

The  symptoms  are  enlargement  of  the  organ,  with  pain  usually  in- 
tense. The  swelling  is  slow  on  account  of  the  great  resistance  offered 
by  the  tunica  albuginea.  The  skin  over  the  organ  is  tense  and  reddened, 
and  at  times  oedematous,  especially  when  an  epididymitis  precedes  the 
inflammatory  process  in  the  testicle. 

In  severe  cases  gangrene  may  ensue,  and  the  tunica  vaginalis  and 
scrotal  walls  may  become  involved.  In  mild  cases  the  pathological 
changes  ai-e  chiefly  hyperaemia  and  the  formation  of  a  limited  amount  of 
embryonic  tissue  along  the  blood-vessels  and  in  the  connective-tissue 
septa  of  this  organ.  In  the  severer  forms  this  process  is  greatly  exag- 
gerated, and  as  a  result  of  the  extensive  hyperplasia  the  circulation  is 
arrested,  and  death  of  the  tubular  structure  ensues.  Or,  if  gangrene 
does  not  occur,  atrophy  of  the  secretory  apparatus  follows  as  a  result 
of  contraction  of  the  products  of  inflammation.  In  some  instances  the 
swelling  subsides,  leaving  no  marked  changes  in  the  organ. 

The  prognosis  is  in  exact  relation  to  the  symptoms.  Mild  cases, 
especially  in  the  forms  occurring  with  urethral  epididymitis,  generally 
terminate  in  one  or  two  weeks  in  recovery  and  restoration  of  the  organ 
to  its  normal  condition.  In  cases  where  the  symptoms  are  severe  from 
the  start,  the  prognosis  is  grave  unless  early  relief  is  afforded,  and  even 
then  it  is  not  always  favorable. 

Treatment. — Eest  in  the  dorsal  decubitus  should  be  insisted  upon  in 
even  the  mildest  cases,  for  not  infrequently  dangerous  orchitis  is  pro- 
voked by  neglect  of  this  precaution. 


746  A  TEXT-BOOK  ON   SURGERY. 

The  position  of  the  testicle  should  be  elevated,  as  in  epididymitis. 
The  local  application  of  cold  is  grateful  and  advantageous  in  most  cases. 
The  organ  is,  however,  so  sensitive  that  no  pressure  is  tolerated.  This 
can  be  obviated  by  making  a  ring  of  cloths  wrapped  around  a  small 
hoop,  leaving  a  lumen  large  enough  to  include  the  scrotum  and  penis. 
The  ice-bag  is  laid  upon  this  ring,  which  prevents  any  pressure  upon  the 
inHamed  organ. 

When  the  effusion  is  rapid,  causing  dangerous  tension  of  the  fibrous 
capsule,  surgical  interference  is  imperative. 

The  operation  consists  in  seizing  the  organ  with  the  left  hand,  so  as 
to  render  it  steady  and  the  skin  tense,  puncturing  the  scrotum  and  pa- 
rietal layer  of  the  tunica  vaginalis  testis,  and  thus  subcutaneously  making 
a  series  of  incisions  through  the  tunica  albuginea  on  its  anterior  and 
antero-lateral  aspects.  The  incisions  should  be  about  half  an  inch  in 
length,  and  are  much  preferable  to  simple  puncture. 

The  danger  of  hernia  testis  does  not  contraindicate  this  procedure. 

Chronic  orchitis,  not  due  to  syphilis,  is  comparatively  rare.  When 
it  occurs,  it  usually  follows  an  acute  inflammation.  The  pathological 
change  consists  in  a  thickening  of  the  tunica  albuginea  and  of  the  con- 
nective-tissue septa.  Embryonic  cells,  collected  in  groups  or  nests,  in 
various  stages  of  development,  are  crowded  along  and  around  the  blood- 
vessels and  seminiferous  tubules,  as  well  as  scattered  about  in  the  inter- 
tubular  spaces.  As  the  process  continues,  the  tubules  disappear  under 
the  pressure  of  the  new  inflammation-tissue.  In  a  certain  proportion  of 
cases  cysts  form  in  the  following  manner :  The  peripheral  cells  of  one  or 
more  foci  of  the  embryonic  tissue  organize  into  connective  tissue  and  aid 
in  forming  the  investing  capsule.  The  cells  within  this  new  capsule  un- 
dergo granular  metamorphosis,  and  later  liquefaction,  by  absorption  of 
fluid  from  the  surroimding  vessels.  In  other  cases  foci  of  suppuration 
(multiple  abscess  of  the  testicle)  may  remain  from  an  acute  inflammation 
and  be  present  in  chronic  orchitis  long  after  the  acute  symptoms  have 
subsided.  The  contents  of  these  foci  may  also  undergo  caseous  degen- 
eration. 

The  symptoms  of  chronic  orchitis  are  those  of  progressive  enlarge- 
ment of  this  organ.  In  some  instances  pain  is  wanting,  in  others  it  is 
present,  though  less  intense  than  in  the  acute  form,  while  in  a  third  cate- 
gory may  be  classed  cases  of  chronic  orchitis  with  intercurrent  attacks 
of  acute  inflammation  and  the  accompanying  exacerbations  of  pain. 
The  organ  varies  in  size  from  two  to  four  or  five  inches  in  its  greatest 
diameter.  Much  annoyance  is  occasioned  in  the  larger  tumors  by  the 
dragging  upon  the  cord. 

The  diagnosis  is  between  hydrocele  of  the  tunica  vaginalis,  inflam- 
mation of  the  walls  of  this  cavity,  with  exudation  and  thickening  and 
adhesion  to  the  testicle,  syphilitic  orchitis,  and  tuberculosis  testis.  Hy- 
drocele is  easily  excluded  by  fluctuation,  translucency,  and  aspiration. 
In  periorchitis  with  exudation  and  adhesions,  differentiation  will  at  times 
be  difficult.  The  obliteration  of  the  cavity  of  the  tunica  vaginalis  renders 
the  superficial  tissues  less  freely  movable  upon  the  body  of  the  testis. 


TUBERCULOSIS   OF  THE  TESTICLE.  747 

In  orchitis  the  surface  of  the  enlargement  is  smooth,  spherical,  and  of 
like  consistence  at  all  points  ;  often  in  periorchitis  ridges  of  new  tissue 
can  be  made  out ;  there  are  soft  spots  or  depressions  which  can  be  recog- 
nised by  careful  palpation. 

If  syphilitic  orchitis  is  suspected  (even  if  the  history  of  this  disease  is 
denied),  it  wiU  be  advisable  to  administer  the  protoiodide  of  mercury  and 
the  iodide  of  potassium  for  several  weeks.  The  marked  diminution  of 
the  tumor  will  be  confirmatory  of  the  siispicion  of  the  syphilitic  dys- 
crasia.  The  extraordinary  weight  of  a  syphilitic  testicle  should  be  borne 
in  mind. 

Tuberculosis  testis  is  usually  preceded  by  the  deposit  of  tuberculous 
matter  in  the  epididymis.  Pain  in  this  affection  is  insignificant  and  en- 
tirely disproportionate  to  the  rapidity  of  the  infiltration  and  enlarge- 
ment. Moreover,  orchitis  and  epididymitis  may  iisually  be  traced  to 
some  direct  and  exciting  cause  which  is  absent  in  tubercular  disease. 

The  indications  in  treatment  are,  first  of  all,  to  remove  every  cause 
of  irritation,  to  keep  up  the  tone  of  the  system  by  judicious  feeding 
and  medication,  and  to  support  the  heavy  organ  by  suspension.  When 
these  measures  fail  to  arrest  the  disease,  or  when  the  pain  becomes  so 
great  that  the  patient's  comfort  is  interfered  with,  or  when  the  disinte- 
gration of  the  organ  is  threatened,  castration  may  be  entertained.  Be- 
fore carrying  out  such  an  extreme  measure,  the  precaution  should  be 
taken  to  explore  the  organ  through  an  incision  in  the  scrotum,  in  order 
to  determine  its  exact  condition  before  removing  it. 

Tuberculosis  of  the  Testicle  and  Epididymis. — True  miliary  tuber- 
culosis of  the  testicle  and  epididymis  is  comparatively  rare.  Many  cases 
which  have  been  recorded  as  tuberculosis  must,  upon  analysis,  be  classed 
with  a  non-tubercular  inflammation,  the  embryonic  tissue  of  which  has 
undergone  caseous  degeneration. 

Tubercular  disease  of  the  testicle  alone  is  the  exception.  The  epi- 
didymis is  usually  first  invaded,  and  from  this  point  the  new  tissue 
spreads  into  the  testicle,  and  not  infrequently  along  the  vas  deferens  to 
the  seminal  vesicles,  as  well  as  to  the  tunica  funiculi  and  tunica  vagi- 
nalis testis. 

While  it  may  be  slow  in  some  instances,  as  a  rule  the  invasion  is 
rapid,  occupying  from  two  to  eight  weeks  in  a  general  infiltration  of 
both  organs.  The  symptoms  are,  upon  the  whole,  obscure.  One  point 
of  great  diagnostic  value  is  that  the  pain  is  entirely  disproportionate  to 
the  rapidity  and  extent  of  the  tumefaction.  In  simple  orchitis  and  epi- 
didymitis, pain  is  extreme  and  pressure  unbearable.  In  tubercular  or- 
chitis pain  is,  as  a  rule,  slight,  and  may  not  be  jiresent  at  all.  In  a 
certain  proportion  of  cases  there  will  be  sudden  and  recurring  exacer- 
bations of  pain,  indicating  a  circuinscribed  acute  orchitis,  the  result  of 
irritation  from  the  presence  of  the  cell-elements  of  the  tubercular  pro- 
cess. Ulceration  and  the  formation  of  fistulse  occur  in  a  certain  propor- 
tion of  cases. 

In  simple  orchitis  and  epididymitis,  the  cord  is  not  involved,  while 
not  infrequently  in  tuberculosis  the  deposit  rapidly  travels  along  the 


748  A  TEXT-BOOK   ON  SURGERY. 

vas  deferens.     Grasped  between  the  lingers,  the  tubercular  organ  is  felt 
to  be  hard,  and  its  surface  uneven  and  nodular. 

The  initial  morbid  change  is  the  deposit  around  the  seminiferous 
tubes  of  clusters  or  nests  of  lymijhoid  cells.  Within  the  tubes  the  endo- 
thelia  are  thickened  and  undergoing  granular  or  caseous  metamorphosis. 
Later,  the  connective- tissue  septa  become  infiltrated  with  the  new  cells. 
The  process  ends  in  compression  and  destruction  more  or  less  complete  of 
the  tubules.  The  centers  of  these  clusters  of  cells  farthest  removed  from 
the  vascular  network  undergo  granular  or  caseous  metamorphosis,  form- 
ing at  times  cyst-like  caverns,  or  at  other  times  abscesses  and  fistulse. 

Treatment. — The  prognosis  of  tubercular  disease  of  these  organs  is 
so  grave  that  when  an  early  diagnosis  can  be  made  out,  exttrpaticm  of 
the  diseased  tissues  should  be  considered.  If  only  one  side  is  involved, 
and  the  other  organ  is  fully  developed,  there  should  be  no  hesitation  in 
advising  the  operation  of  castration. 

When  the  diagnosis  is  doubtful,  it  will  be  wise  to  keep  the  patient 
under  constant  observation,  with  especial  regard  to  the  advance  of  the 
disease  along  the  cord,  and  when  this  is  evident,  and  when  there  is  no 
positive  evidence  of  tubercular  deposits  elsewhere,  extirpation  is  indi- 
cated in  order  to  prevent  invasion  of  the  prostate  and  general  dissemi- 
nation. When  both  organs  are  involved,  the  question  of  complete  cas- 
tration is  one  of  doubtful  propriety. 

Enchondroma  of  the  testicle  is  not  altogether  infrequent.  It  occurs 
most  often  after  injury.  While  it  is  prone  to  originate  in  the  organ,  it 
may  spread  from  the  epididymis  to  the  testicle.  The  volume  of  the  organ 
varies,  at  times  reaching  a  large  size.  Enchondroma  testis,  as  with  al- 
most all  forms  of  neoplasm  seated  in  this  structure,  is  apt  to  undergo 
cystic  degeneration. 

The  diagnosis  must  be  based  uj^on  the  hard,  elastic  feel  peculiar  to 
this  form  of  tumor. 

The  treatment  is  either  expectant  or  operative,  as  circumstances  may 
demand.  Castration  is  indicated  when  the  disease  is  unilateral,  and 
when  the  size  of  the  tumor  is  such  that  the  function  of  the  opposite  organ 
is  threatened. 

Adenoma  testis  occiirs  chiefly  from  the  twentieth  to  the  fortieth  year 
of  life.     It  has  so  far  not  been  observed  during  childhood. 

The  development  of  the  tumor  is  usually  rajnd,  attaining  a  diameter 
of  three  or  four  inches  or  more.  Only  one  organ  is  usually  affected. 
Pain  is  not  a  prominent  symptom  in  the  earlier  history  of  this  neo- 
plasm, but,  after  the  growth  attains  a  sufficient  bulk,  it  causes  more  or 
less  pain  by  pressure  and  weight.  To  the  touch  it  is  soft  and  compres- 
sible. The  formation  of  cysts  in  various  portions  of  the  neoplasm  is 
frequent  (cysto-adenoma)  (Fig.  664). 

Under  the  microscope  the  epithelia  of  the  seminiferous  tubules  are 
seen  to  be  swollen,  while  their  caliber  is  more  or  less  completely  occluded 
with  the  round  cells  of  the  new  (adenoid)  tissue. 

The  prognosis  is  not  favorable,  and  the  diagnosis  difficult.  Since  the 
function  of  the  organ  is  wholly  impaired,  and  since  the  rapid  develop- 


CARCINOMA— SARCOMA  TESTIS. 


749 


ment  of  the  tumor  is  of  itself  an  indication  of  the  gravity  of  the  lesion, 
the  matter  of  exact  recognition  of  adenoma  is  not  important.  In  all  of 
these  rapid  and  threatening  neoplasms,  especially  when  a  single  testicle 

or  epididymis  is  involved,  the  safest 
course  is  in  early  and  prompt  ex- 
cision. 

Carcinoma. — Both  scirrhus  and 
medullary  cancer  may  develop  pri- 
marily in  the  testicle  or  epididymis. 
The  encephaloid  variety  is  most  fre- 
quently encountered.  The  micro- 
scopical characters  of  these  different 
varieties  of  cancer  will  be  given  in 
the  chapter  on  tumors. 

Carcinoma  of  the  testis  is  apt  to 
occur  about  the  age  of  puberty,  al- 
though it  may  be  met  with  later  in 
life.  One  organ  is  affected  as  a  rule. 
It  is  more  apt  to  begin  in  the  tes- 
ticle than  in  the  epididymis.  In  the 
early  stages  of  the  development  can- 
cer of  the  testes  is  not  painful,  but 
as  the  disease  advances  the  suffer- 
ing may  be  intense.  Early  removal 
offers  the  only  hope  of  cure,  and 
this,  unfortunately,  is  not  great. 
Sarcoma  testis  occurs  at  all  ages,  but  is  chiefly  confined  to  childhood 
and  early  manhood.  Following  the  general  law  of  sarcomata,  that  of 
the  testicle  is  rapid  in  growth,  attaining  at  times  an  enormous  size.  This 
is  one  of  the  chief  diagnostic  points  of  this  tumor,  which  is  hard,  usually 
pyriform  in  shape,  and  of  comparatively  smooth  contour.  Castration 
offers  the  only  hope  of  relief. 

It  will  be  seen  from  the  foregoing  that  accurate  diagnosis  of  the  va- 
rious neoplasms  which  develop  in  the  testicle  is  difficult  and  often  im- 
possible. Almost  aU  of  these  morbid '  processes  lead  to  destruction  of 
the  organ  and  loss  of  function,  and  immediately  or  remotely  threaten 
the  life  of  the  individual. 

Thus  tuberculosis,  adenoma,  carcinoma,  and  sarcoma  may  be  classed 
as  malignant.  Enchondi-oma,  although  not  intrinsically  malignant,  leads 
to  loss  of  function,  and  in  this  particular  justifies  operative  interference. 
The  same  applies  with  greater  force  to  cystic  degeneration  of  this  organ, 
since  cysts  often  develop  in  malignant  neoplasms  of  the  testicle.  In  view 
of  these  facts,  when  only  a  single  organ  is  involved,  it  will  be  advisable 
in  the  early  history  of  any  neoplasm  of  this  organ  to  consider  the  pro- 
priety of  castration. 

The  operation  is  thus  performed  :  Shave  the  scrotum  and  pubes,  and 
make  an  incision  extending  from  the  external  abdominal  ring  along  the 
anterior  surface  of  the  cord  and  testicle  to  the  base  of  the  scrotum. 


Fig.  664. — Cystic  degeneration  of  iidenoma  of  the 
testicle  (cysto-adenoma).     (Alter  Kocher.) 


750  A  TEXT-BOOK  ON   SURGERY. 

When  tlie  morbid  process  inTolves  the  scrotal  tissues,  and  even  when 
there  is  a  suspicion  of  involvement,  the  jsrimary  incision  should  be  car- 
ried well  away  from  the  suspected  tissue  into  the  healthy  structures. 

Two  points  of  importance  are  suggested  in  the  removal  of  this  organ. 
The  first  is  to  make  an  incision  into  the  mass  in  order  to  clear  up  the 
diagnosis ;  the  second  is  to  secure  the  vessels  by  the  ligature  applied 
near  the  external  ring,  and  thus  prevent  the  danger  of  forcing  septic  or 
metastatic  matter  in  the  lymph  channels  or  vessels  leading  toward  the 
center.  The  cord  should  be  exposed  at  the  ring,  the  vas  deferens  iso- 
lated, and  a  large,  double  catgut  ligature  thrown  around  so  as  to  include 
the  entire  cord  except  the  vas  deferens.  This  is  twisted  around  the  cord 
while  the  exploratory  incision  is  being  made,  and,  if  the  diagnosis  is 
confirmed,  the  catgut  is  tied  and  the  cord  divided  between  the  two  liga- 
tures. The  diseased  organ  is  then  dissected  out,  the  hgemorrhage  ar- 
rested, a  drainage-tube  introduced,  and  the  wound  closed  with  catgut 
sutures.  A  single  dressing  will  usually  suflBce.  When  the  vas  deferens 
is  divided,  the  accompanying  artery  will  have  to  be  separately  tied. 

Malposition. — One  or  both  of  these  organs  may  be  absent  from  the 
normal  position  in  the  scrotal  sac.  The  descent  from  the  abdominal 
cavity  may  be  prevented  by  narrowing  or  closure  of  the  inguinal  rings, 
or  the  inner  ring  may  be  passed,  the  testicle  being  arrested  at  the  outer 
opening,  and  thus  imprisoned  in  the  canal ;  or,  passing  both  rings,  it 
may  lodge  beneath  the  skin  near  the  pubic  crest,  or  in  the  perinseum  or 
groin.  Occasionally  the  testicle  remains  entirely  within  the  abdominal 
cavity.  Another  rare  form  of  malposition  is  when  the  organ  is  turned 
obliquely  or  crosswise  in  the  scrotum. 

Misplaced  testicle  does  not  iisually  give  rise  to  great  inconvenience 
until  the  approach  of  puberty,  when  its  normal  development  is  inter- 
fered with  by  compression.  If  it  is  lodged  in  the  inguinal  canal,  where 
it  is  acted  upon  by  muscular  contraction,  it  may  cause  pain  at  an  earlier 
period.  The  descent  of  a  hernia  upon  a  testicle  thus  imprisoned  gives 
rise  to  considerable  annoyance.  An  imprisoned  testicle  is  occasionally 
the  seat  of  a  neoplasm.  The  symptoms  are  those  of  pain,  neuralgic  in 
character,  and  the  diagnosis  must  depend  upon  the  absence  of  the  organ 
from  its  normal  place  and  its  recognition  in  the  position  of  the  abnormal 
swelling. 

Misplaced  testicle  requires  no  special  treatment  until  it  becomes  a 
source  of  inconvenience  or  annoyance,  or  is  the  seat  of  some  new  forma- 
tion.    Extirpation  is  then  demanded. 

Supernumerary  testicle  does  not  occur.  In  several  instances  a  cyst  or 
other  neoplasm  has  been  mistaken  for  an  extra  organ. 


CHAPTER  XX. 


THE   GEXITO-UEIXAEY   ORGANS   IX   FEMALES. 


Lesions  of  the  Vulva  and  Perinaum — Wounds. — Incised  or  lacer- 
ated wounds  of  the  vulva  are  frequently  accompanied  by  profuse  hfemor- 
rhage,  especially  when  the  venous  plexuses  which  compose  the  bulbs  of 
the  testibule,  on  either  side  of  the  vaginal  orifice,  or  the  large  connect- 
ing veins  which  extend  uj^ward  to  the  clitoris,  are  divided.  Incision  or 
rapture  at  or  near  the  median  line,  the  posterior  commissure  of  the 
vulva,  is  not  followed 
by  haemorrhage,    as   a  y 

rule,  since  the  vascu- 
lar network  does  not 
extend  so  low. 

Bleeding  may  be  ar- 
rested by  direct  com- 
pression with  a  pledget 
of  gauze  or  lint,  or,  in 
case  of  extensive  in- 
jury, by  the  ligature. 
The  employment  of 
styptic  cotton  is  objec- 
tionable on  account  of 
the  inflammation  which 
it  may  cause. 

Contusions  of  this 
part  of  the  genital  ap- 
paratus may  be  fol- 
lowed by  hcematoma  or 

abscess.    Hgematoma  also  occirrs  in  rare  instances  in  pregnant  women 
from  over-distention  and  rupture  of  the  veins  without  direct  violence. 

In  this  variety  of  swelling  oj^erative  interference  is  not  advisable,  un- 
less the  tumor  is  so  large  that  it  seriously  interferes  with  the  comfort  of 
the  patient,  or  unless  sloughing  is  imminent  or  suppuration  supervenes. 
When  abscess  occurs,  it  should  be  incised  and  drainage  established. 
Abscess  here  is  most  frequently  situated  in  the  region  of  Bartholin's 
gland,  between  the  vaginal  orifice  and  the  erector  clitoridis  muscle. 
Boils  are  not  infrequent  in  this  same  location,  and  require  to  be  opened, 


Fig.  665. — Showing  arrangement  of  the  erectile  tissue  and  venous 
plexuses  about  the  vulva,  a,  Bulb  of  vestibule.  6,  Clitoris. 
c,  Connecting  veins,  d,  Dorsal  vein  of  clitoris,  e,  /,  Deeper 
veins,  g,  h.  Communication  between  obturator  and  vulvar  ves- 
sels.    (After  Quain.) 


752 


A  TEXT-BOOK  ON  SURGERY. 


kept  clean  by  constant  care,  and  when  sluggish  in  healing  should  be 
touched  thoroughly  with  lunar  caustic. 

As  a  result  of  injury,  and  occasionally  as  a  congenital  affection,  adhe- 
sions of  the  labia  exist.  This  condition  should  not  be  mistaken  for  the 
Jiymen,  which  membrane  is  situated  farther  inward.  The  treatment 
requii'ed  is  a  careful  separation  of  the  adhering  surfaces  in  the  median 
line  and  the  insertion  of  a  plug  of  gauze  or  a  glass  cylinder,  which  is 
allowed  to  remain  until  the  raw  surfaces  become  covered  with  epithelia. 

Rupture  of  the  Posterior  Commissure  of  the  Vulva  and  Perinceum. 
— Rupture  of  the  perinaeum  may  be  partial  or  complete.  In  partial 
rupture,  the  laceration  may  involve  the  tissues  down  to  or  partly  through 
the  sphincter -ani  muscle.  Complete  laceration  extends  through  to  the 
anus  and  involves  more  or  less  of  the  recto-vaginal  septum  and  wall  of 
the  rectum.  In  very  rare  instances,  the  laceration  is  central,  in  which 
case  a  sinus  is  developed,  extending  from  the  inferior  vaginal  wall  or 
floor  to  some  point  on  the  peringeum,  the  fourchette  and  sphincter  ani 
remaining  intact. 

Rupture  of  the  peringeum  may  occur  at  any  stage  of  the  child-bearing 
period.  The  frequency  of  this  accident  is  in  general  proportionate  to 
the  size  of  the  child,  the  rapidity  of  delivery,  and  the  age  of  the  mother 
at  the  period  of  first  confinement. 

A  breech  presentation,  in  which  the  head  and  arms  are  crowded 
together  through  the  vagina  and  vulva  is  apt  to  produce  severe  lacera- 
tion, especially  when,  in  order  to  prevent  too  prolonged  pressure  on  the 


Oponin?  of  urethra. 
Opening  of  vagina. 


Perineal  body. 


Fig.  665  a. — Show  ins  in  perpendiculii  "section  the  perineal  borlv,  and  its  support  to  the 
bladder,  %agina,  and  rectum      ^Atter  Thoma.s  ) 

chord,  rapid  delivery  is  necessary.  Rapid  expulsion  of  the  child  by  the 
first  few  and  violent  uterine  contractions,  or  by  the  use  of  forceps  before 
natural  dilatation  has  been  effected,  will  add  greatly  to  the  danger  of 


OLD   INCOMPLETE   Rt^PTURE   OF   THE   PERINEUM. 


753 


rupture  of  the  perinseum.  Parturition  occurring  for  the  first  time  after 
the  thirtieth  year  of  life  is  also  more  apt  to  be  attended  with  laceration 
of  the  peringeum  than  at  an  eai-lier  period,  when  the  tissues  are  more 
yielding. 

There  may  result  from  perineal  lacerations :  Jicemorrliage,  and  loss  of 
function  in  the  sjihincter-ani  muscle,  rectocele,  cystocele,  proctitis, 
cystitis,  prolapsus,  and  other 
displacements  of  the  uterus 
and  its  appendages  (Fig.  665  a 
and  Fig.  665  b). 

Treatment. — The  indications 
are  to  restore  as  near  as  possi- 
ble the  normal  relations  of  the 
separated  tissues.  In  incom- 
plete rupture,  or  even  when  the 
laceration  extends  barely  into 
the  anal  margin,  the  iest  time 
to  operate  is  immediately  after 
the  delivery  of  the  placenta. 
The  contra-indications  to  oper- 
ative interference  here  are  ex- 
haustion by  reason  of  hfemor- 
rhage,  or  a  prolonged  and  diffi- 
cult labor. 

In  complete  rupture  of  the 
recto-vesical  septum  the  opera- 
tion  is    of    necessity    so    pro- 
longed that  it  is  advisable  to  wait  until  involution  has  taken  place,  and 
the  patient's  vigor  is  restored. 

Operation  for  Old  Incomplete  Rupture  of  the  PerincBum. — Prepare 
the  patient  by  emptying  the  alimentary  canal  of  fecal  matter,  for  six 
days  before  the  operation.  Fluid  extract  of  cascara  sagrada  iri  x-xxx, 
three  times  a  day,  or  Hunyadi  water  before  breakfast,  will  secure  free 
discharges.  Liquid  diet  should  be  ordered  for  the  last  three  days  of 
preparation,  and  a  copious  enema  given  on  the  morning  of  operation. 
No  laxatives  should  be  administered  within  twenty-four  hours  of  the 
operation. 

The  instruments  and  material  required  are  a  pair  of  sharp-pointed 
scissors  curved  on  the  fiat,  a  tenaculum  or  good  tissue  forceps,  a  strong 
needle-holder,  some  strong  round  needles,  without  cutting  edges,  with  a 
half -curve  near  the  point,  varying  from  about  one  and  a  half  to  two  inches 
in  length,  each  armed  with  a  loop  of  fine  strong  Chinese  twisted  silk,  for 
carrying  the  wire  through,  some  silver- wire  sutures,  one  foot  long  each 
(jSTo.  27  for  deep,  No.  33  for  superficial  sutures),  a  piece  of  small-sized 
rubber  tubing.  By  holding  the  end  of  the  silver  wire  over  a  spirit-lamp, 
it  melts  and  is  easily  shaped  into  a  shot,  which  prevents  it  from  being 
accidentally  jerked  through  when  introduced. 

Place  the  patient  upon  the  table  on  the  back,  the  sacrum  near  the 

48 


Fig.  665  b.— Eectoeele  and  cystocele   followins  destrac- 
tion  of  the  perineal  body.     (After  Thomas. ) 


754 


A   TEXT-BOOK   ON   SURGERY. 


edge,  the  legs  flexed  on  the  thighs,  and  the  separated  thighs  flexed  on 
the  abdomen,  and  held  by  two  assistants,  who  also  separate  the  labia. 

Irrigate  the  vagina,  vulva,  and  anal  region  with  l-to-3000  corrosive 
sublimate  solution  and  thoroughly  dry  these  organs  with  sponges.  A 
close  inspection  of  the  torn  surfaces  should  now  be  made,  so  that  the 
full  extent  of  the  laceration  may  be  realized.  This  will  not  be  diffi- 
cult to  determine,  since  the  peculiar,  glistening,  smooth  surface  of  the 
cicatrix  is  readily  made  out.  By  carefully  approximating  these  sur- 
faces before  using  the  scissors,  the  extent  of  denudation  may  be  appre- 
ciated. The  clover-leaf  shape  of  the  denuded  area  is  well  shown  in  Fig. 
665  c,  extending  upward  along  the  labium  of  either  side  and  well  up 

into  the  depression  or  angle, 
where  the  floor  of  the  vagina  and 
labium  come  together.  Upon 
the  floor  of  the  vagina  the  de- 
nudation should  extend  back- 
ward to  the  crest  of  the  recto- 
cele  or  elevation  formed  by  the 
bulging  forward  of  the  floor  of 
the  vagina.  The  tissue  to  be  re- 
moved in  fx-eshening  the  torn 
surfaces  should  be  picked  up 
by  the  tenaculum  or  forceps, 
and  shaved  off  with  the  scissors. 
It  is  advisable  to  commence  at 
the  lowest  portion  of  the  scar 
by  taking  up  a  strip  from  the 
patient's  left  directly  across  the 
perinseum  to  the  right  (from  C 
to  1,  1  to  C,  Fig.  665  c).  In  this 
way  the  parts  yet  to  be  lifted 
are  not  obscured  by  the  bleeding. 
Denudation  of  the  vaginal 
floor  can  be  most  rapidly  accomplished  by  inserting  one  or  two  fingers 
into  the  rectum  and  making  tense  and  elevating  the  surface  to  be  fresh- 
ened over  the  ends  of  the  fingers. 

The  sutures  are  now  introduced,  commencing  with  No.  1  (Fig.  665  c), 
near  the  sphincter  ant.  They  should  be  inserted  about  one  fourth  of 
an  inch  apart  and  the  needle  should  enter  the  same  distance  from  the 
edge  of  the  wound.  It  is  well  to  include  a  liberal  quantity  of  tissue. 
As  the  needle  is  carried  through  from  the  (patient's)  left  to  right  side,  it 
should  be  carefully  guided,  so  that  it  does  not  emerge  at  any  point  oh 
the  denuded  surface  (nor  by  any  mishap  i^enetrate  into  the  rectum), 
and  finally  be  brought  out  through  the  integument  of  the  right  side  at  a 
point  exactly  opposite  its  entrance.  As  each  suture  is  passed,  the  finger 
in  the  rectum  will  enable  the  operator  to  guide  the  needle  safely  through 
the  recto-vaginal  septum.  After  two  or  three  sutures  are  passed,  on 
account  of  the  distance  across  the  denuded  area,  it  may  be  necessary  to 


Fie.  665  0. — Operation  for  diminishing  tlie  vaginal  out- 
let by  external  sutures  alter  rupture  of  the  peri- 
nsfium.     (After  Emmet.) 


A 


IMMEDIATE    PERINJEORRAPHY.  755 

bring  the  needle  out  in  the  middle  line.  It  should  be  reintroduced  at 
the  same  point,  so  that  the  suture  will  not  be  exjjosed. 

The  suture  next  to  the  last  {D,  Fig.  665  c),  after  passing  through  the 
labium,  is  not  made  to  pass  into  the  recto-vaginal  septum  until  the 
needle  approaches  the  middle  line  of  the  septum,  where  it  is  j^assed 
through  this  for  about  the  extent  of  one  inch. 

The  uppermost  suture  of  all  (C,  Fig.  665  c)  enters  at  the  upper  limit 
of  the  freshened  surfaces,  passes  through  the  labium,  comes  out  in  the 
cavity  of  the  vagina,  and  then,  just  above  the  limit  of  the  denudation  on 
the  recto-vaginal  septum,  it  is  made  to  traverse  this  for  about  one  half 
of  one  inch  (an  auxiliary  or  supporting  suture).  As  each  wire  is  drawn 
through,  the  ends  should  be  loosely  twisted  to  prevent  being  pulled  out 
by  accident.  When  all  are  inserted,  the  wound  should  be  thoroughly 
cleansed  and  disinfected  with  sublimate  solution  and  the  wires  twisted, 
commencing  with  the  lowest, 
No.  1.  The  twisted  ends  are 
left  about  two  inches  long,  are 
gathered  together  in  a  bundle 
(Fig.  665  d),  and  included  in  a 
piece  of  soft  rubber  tubing  held 
in  place  by  a  bit  of  thread. 

The  patient's  thighs  should 
be  bandaged  together.  She  may 
rest  on  the  back  or  side  as  pre- 
ferred, and  the  catheter  should      1       j,^^  eesD.-Sutures  twisted,  and  the  ends. 

be  employed   every  five  or  seven        f'^  covered  with  a  piece  of  rubber  tube. 

hours,  in  cases  where  the  urine 

can  not  be  naturally  voided.  It  should  be  the  operator's  aim  to  permit 
no  movement  of  the  bowels  for  two  or  three  days,  and  when  this  occurs 
an  enema  of  warm  water  should  be  employed  to  secure  a  soft  or  liquid 
discharge.  The  passage  of  solid  matter  will  seriously  endanger  the  suc- 
cess of  the  operation. 

The  sutures  should  be  removed  in  eight  or  ten  days.  The  most  suit- 
able position  is  with  the  patient  on  the  back,  the  thighs  held  together 
and  flexed  well  upon  the  abdomen.  The  lowest  wire  is  first  disengaged 
and  gently  puUed  upon  until  the  right  side  (patient's  left)  of  the  buried 
loop  is  seen,  when  the  scissors'  point  is  passed  beneath  and  made  to 
divide  it.  Care  should  be  taken  not  to  separate  the  barely  united  sur- 
faces, and  this  is  best  avoided  by  drawing  the  twisted  stub  of  the 
divided  suture  toward  the  side  on  which  it  was  cut.  Abduction  of  the 
thighs  should  not  be  allowed  until  about  the  fourteenth  day. 

Immediate  Perinceorrapliy.—kltfir  the  placenta  has  been  expelled,  the 
uterus  should  be  firmly  compressed  in  order  to  cause  rapid  and  thorough 
contraction,  and  also  to  force  out  any  remaining  clots  of  blood.  The 
vagina  should  then  be  irrigated  with  warm  l-to-3000  sublimate  solution, 
and  a  soft,  small-sized  sponge  inserted  to  prevent  the  descent  of  any 
fluids  from  the  uterus  while  the  sutures  are  being  passed.  These  are 
inserted  in  the  same  way  as  just  described  for  secondary  perinseorraphy, 


756 


A  TEXT-BOOK  ON  SURGERY. 


Fig.  665  e. — Surface  denuded  in  com- 
plete perineal  rupture,  and  the  first 
two  sutures  in  position.  (After 
Thomas.) 


and  the  freshly  lacerated  surfaces  untouched  by  the  scissors  are  at  once 
approximated.     The  vaginal  sponge  tampon  is  now  removed.     The  after- 
treatment  does  not  differ  from  that  above 
given. 

Secondary  Operation  for  Complete  Lac- 
eration of  the  Perinceum. — The  most  rigid 
preparatory  treatment  should  be  carried 
out,  the  object  being  to  empty  the  entire 
alimentary  canal  of  all  solid  matter,  and 
to  prevent,  as  far  as  possible,  the  accumu- 
lation of  gas.  To  this  end  a  liquid  diet 
should  be  ordered  for  one  week  before  the 
operation,  a  copious  enema  of  warm  water 
and  inspissated  ox-gall  should  be  given 
daily,  and  on  alternate  days  a  free  laxa- 
tive, discontinuing  the  latter  twenty-four 
hours  before  the  operation. 

The  chief  objects  of  this  operation,  given 
in  order  of  importance,  are  :  (1)  restoration 
of  the  functions  of  the  sphincter-ani  mus- 
cle, and  (2)  restoration  of  the  perineal  body. 
The  denudation  should  extend  along  the 
triangular  cicatricial  surface  of  each  half  of 
the  divided  periaseum  and  entirely  along  the  edges  of  the  I'ent  in  the 
recto-vaginal  septum.  For  the  first  suture,  the  needle  is  introduced 
just  at  the  margin  of  the  anus  and  one  quarter  of  an  inch  from  the 
denuded  surface.  It  is  now  directed  through  the  recto-vaginal  sep- 
tum to  the  angle  of  the 
rent,  then  back  along  the 
opposite  side,  and  made 
to  emerge  at  a  point  cor- 
responding to  its  insertion 
(Pig.  665  e).  Great  care 
should  be  taken  to  prevent 
the  needle  entering  the  rec- 
tum. A  second  suture  is 
passed  parallel  with  this. 
The  remaining  sutures  are 
inserted  as  in  the  opera- 
tion for  incomplete  rupt- 
ure. The  bowels  should 
not  be  allowed  to  move  for 
four  or  five  days  after  the 
operation,  and  then  an 
enema  should  be  adminis- 
tered by  the  physician.  Should  gas  accumulate  in  the  rectum,  it  may 
be  removed  by  the  careful  insertion  of  a  small  soft  catheter. 

When  the  rent  in  the  recto- vaginal  septum  is  bifid  (a  rare  occurrence) 


Fig.  665  F. — The  direction  of  the  sutures  in  a  cleft  laceration 
through  the  recto-vaginal  septum.     (After  Emmet.) 


DISEASES   OF   THE   VULVA.  757 

the  edges  should  be  correspondingly  freshened,  and  the  sutnres  inserted 
as  shown  in  Fig.  665  f.  The  sutures  should  be  removed  on  the  eighth  or 
tenth  day  (Emmet). 

When  the  laceration  is  central,  it  is  advisable  to  incise  the  strip  of 
tissue  between  the  sinus  and  the  fourchette,  pare  the  edges  of  the  lacera- 
tion, and  insert  sutures  as  in  the  operation  for  incomplete  rupture. 

Diseases  of  the  Vulva. — The  vulva  and  adjacent  cutaneous  surfaces 
may  be  the  seat  of  syphilitic,  chancroidal,  tubercular,  and  epithelial 
ulcers,  of  ulcers  resulting  from  abrasions  or  fissures  which  have  been  in 
contact  with  gonorrhoeal  virus,  a  leucorrhoeal  discharge,  or  the  urine ; 
and  of  warty  excrescences  (condylomata). 

The  primary  lesion  of  syphilis  and  the  chancroidal  ulcer  in  this 
location  do  not  differ  materially  from  those  already  given.  Tubercular 
ulcers  follow  a  chronic  course  ;  they  are  irregular  in  outline,  and  are 
characterized  by  a  deeper  infiltration  of  the  subcutaneous  tissues  than  in 
the  acute  forms  of  ulcers.  Epithelioma  of  the  vulva  possesses  the  same 
characteristics  as  given  for  this  condition  on  other  mnco-cutaneous  sur- 
faces.    Condylomata  have  already  been  considered. 

Treatment. — A  typical  syphilitic  ulcer  requires  no  local  treatment. 
Whenever  any  ulcer  of  this  region  takes  on  a  phagsedenic  character  it 
should  be  at  once  thoroughly  cauterized.  I  prefer  the  red-hot  wii-e  or 
Pacquelin's  cautery.  If  these  agents  can  not  be  employed,  pure  nitric 
acid  will  sufiice.  The  injection  into  the  tissues  beneath  and  around  the 
ulcer,  of  from  gtt.  v-xx  of  a  4-per-cent  solution  of  cocaine  hydrochlo- 
rate,  renders  the  free  use  of  the  cautery  painless.  After  destroying 
the  ulcer,  an  ointment  of  cocaine  hydrochlorate,  gr.  ij,  iodoform  gr.  j, 
morph.  sulph.  gr.  ss.,  olei  theobrom.  q.  s.,  may  be  applied  as  an  emol- 
lient local  ansesthetic. 

Lupoid  or  tubercular  ulcers  should  be  dissected  out,  or  deeply  in- 
jected with  pure  liquid  carbolic  acid,  until  sloughing  is  produced.  Mild 
forms  of  this  ulcer  may  be  cured  by  scraping  with  a  sharp  spoon  or  ring- 
scoop,  and  repeating  this  procedure  at  intervals  of  two  weeks,  until  cica- 
trization ensues.  Epitheliomata  should  be  freely  excised.  Papillomata 
may  be  radically  destroyed  by  clipping  them  ofi'  with  curved  scissors 
and  burning  the  stump  with  nitric  acid.  In  all  forms  of  ulcer  of  the 
vulva  complicated  with  vaginal  discharge,  repeated  iragation  of  this 
canal  with  warm  sublimate  solution  l-to-5000  should  be  practiced. 

Yultitis  from  direct  injury  should  be  treated  by  complete  rest,  aided 
by  the  sitz-bath  of  warm  water  and  by  emollient  applications. 

Oonorrhoea  in  the  female  is  not  infrequently  confined  to  the  vulva 
and  meatus  urinarius,  but  may  extend  to  the  vagina,  uterus,  and  tubes, 
and  to  the  bladder.  The  symptoms  of  inflammation  supervene,  as  a  rule, 
rajjidly  after  the  contact,  there  being  first  noticed  a  sense  of  burning  over 
the  meatus  and  along  the  urethra,  especially  severe  during  and  immedi- 
ately after  micturition.  There  soon  follows  a  purulent  and  occasionally 
a  bloody  discharge  from  the  urethra  and  vagina.  The  diagnosis  of  gon- 
orrhoea in  the  female  is  not  so  easily  made  as  in  the  male,  since  a  vaginal 
discharge  not  specific  in  character  may  conceal  the  true  nature  of  the 


758  A  TEXT-BOOK   ON  SURGERY. 

disease.  The  discliarge  directly  from  the  meatus  is  the  most  direct 
symptom  of  gonorrhoea.  In  the  treatment^  complete  rest  is  indicated. 
The  warm  sitz-bath  is  of  great  importance.  Irrigation  of  the  vagina 
with  warm  l-to-5000  sublimate  solution  (or  a  weaker  mixture,  should 
this  prove  painful)  should  be  performed  two  or  three  times  a  day.  If 
commenced  early  in  the  disease,  the  invasion  of  the  uterus  may  be  pre- 
vented ;  this  is  of  vast  importance,  since  serious  lesions  {sterility,  pyo- 
salpinx,  etc.)  may  result  from  gonorrhoeal  inflammation  of  the  uterus 
and  Fallopian  tubes.  I  do  not  think  injections  of  the  urethra  are  indi- 
cated, certainly  not  in  the  early  stages.  The  administration  of  Vichy 
water,  alkaline  diluents,  citrate  of  potash,  etc.,  will  suffice  to  irrigate 
this  channel  by  increasing  the  flow  of  urine. 

Boils  are  not  infrequently  met  with  in  the  labia,  and  should  be  treated 
as  when  occurring  elsewhere. 

Pruritus  vulvw  is  a  distressing  and  often  an  obstinate  disease. 
The  sense  of  itching,  burning,  or  formication  may  be  felt  at  the  vulva,  in 
the  vagina,  or  over  the  entire  pudendal  region.  It  is  paroxysmal  in 
character  ;  the  attacks  may  occur  at  all  times,  but  more  frequently  are 
severest  immediately  after  the  j)atient  goes  to  bed.  This  condition  is 
met  with  in  females  of  all  ages,  but  is  more  apt  to  occur  about  the  cessa- 
tion of  the  menses.  In  addition  to  superficial  lesions  of  the  genital  organs, 
displacement  of  the  uterus,  chronic  inflammation  of  the  vagina,  or  any 
disorder  of  the  deeper  organs,  may  cause  pruritis  of  the  vulva.  The 
indications  in  treatment  are  to  correct  any  existing  pathological  condi- 
tion. Grailly  Hewitt  advises  a  mixture  of  one  part  of  chloroform  to  six 
of  almond-oil. 

Hernia  of  the  labium  may  be  recognized  from  the  history  of  the  case, 
the  tumor  having  first  been  noticed  above  at  the  canal  of  Nuck,  descend- 
ing more  or  less  gradually  into  the  labium. 

Cystic  tumors  here  originate  in  the  substance  of  the  labium. 

Hernia  of  the  ovary  occasionally  is  met  with.  The  diagnosis  maybe 
made  as  follows  :  In  hernia  of  the  bowel  or  omentum  an  impulse  will  be 
;transmitted  on  coughing ;  it  may  be  reducible ;  it  is  first  observed  in 
.the  canal  of  Nuck,  extending  subsequently  into  the  labium.  A  pro- 
lapsed ovary  is  painful  on  presstire,  giving  a  peculiar  sensation  not  met 
with  in  compression  of  a  cyst  or  loop  of  intestine.  The  character  of  a 
cyst  may  be  positively  determined  by  exploration  with  a  very  fine  and 
thoroughly  aseptic  hypodermic  needle  and  syringe.  An  exacerbation 
of  pain  in  a  tumor  in  this  locality,  about  the  menstrual  period,  would 
suggest  the  presence  of  a  misplaced  ovary. 

The  treatment  of  hernia  in  the  female  is  given  elsewhere.  A  prolapsed 
ovary  should  be  extirpated,  and  a  cyst  of  the  labium  or  canal  of  ISTuck 
should  be  removed. 

The  Vagina— Vaginitis.— hi?L&mmdut\on  of  the  vagina,  whether  trau- 
matic or  idiojyatMo.  should  be  treated  by  rest,  ii-rigation,  and  the  sitz- 
bath.  In  the  acute  form,  warm  boracic-acid  solution  (Thiersch)  is  pref- 
erable. The  patient  should  lie  on  the  back,  the  sacrum  resting  upon  a 
bed-pan,  and  the  solution  applied  by  means  of  a  fountain  irrigator  from 


VAGINISMUS— STRICTURE   OF   THE   VAGINA.  759 

a  height  sufficient  to  give  the  stream  considerable  force.  As  soon  as 
the  more  acute  symptoms  have  subsided — and  in  all  forms  of  chronic 
vaginitis— the  thorough  application  of  nitrate  of  silver,  3  j-ij  to  water  ^  j 
is  indicated.  The  irrigation  should  be  resumed  in  about  thirty-six 
hours  after  the  nitrate-of-sUver  solution  has  been  brushed  over  the  sur- 
faces of  the  vagina.  This  application  may  be  repeated  in  from  five  to 
eight  days,  as  needed.  Before  introducing  the  stronger  solution,  it  is 
advisable  to  cover  the  external  genitals  with  vaseline  to  jorevent  the 
burning  which  would  otherwise  occur  on  the  exposed  surfaces. 

Vaginismus,  or  "spasm  of  the  vagina,"  is  chiefly  due  to  an  abnor- 
mally sensitive  condition  of  the  vaginal  orifice.  Vaginitis  is  not  usually 
present.  Upon  introducing  the  finger,  the  hymen  will  often  be  found 
tense  and  resisting.  An  efi'ort  to  carry  the  finger  into  the  vagina  will  be 
extremely  painful,  and  will  cause  spasm  of  the  sphincter-vaginse  muscle. 

Treatment. — Place  the  anaesthetized  patient  on  the  back,  with  the 
sacrum  resting  on  the  edge  of  the  table,  the  thighs  separated  and  held  by 
assistants.     With  the  hymen  exposed  by  holding  the  labia  apart,  seize 
this  membrane  with  a  mouse- 
tooth  forceps  and  dissect  it 
out  close  to  its  vaginal  at- 
tachments.     Introduce     two 
fingers,  dilate  the  vagina,  and 
with  the  knife  make  two  par- 
allel incisions  on  the  lateral 

aspects     of     the     vaginal     wall  Fia.  665  o.-Sims's  glass  vaginal  plug 

throughout  its  length.    These 

incisions  should  extend  about  through  the  vaginal  wall.  Then  intro- 
duce the  Sims's  glass  vaginal  plug  (Fig.  665  g),  adjusting  the  instrument 
so  that  the  urethra  will  fit  into  the  concavity  on  its  upi)er  surface.  It 
should  be  removed  in  six  or  eight  hours,  the  vagina  irrigated  and  the 
cylinder  reintroduced.  After  the  first  twenty-four  hours  it  may  be  worn 
three  or  four  hours  daily.  This  should  be  kept  up  for  two  or  three 
weeks,  or  until  all  trace  of  the  vaginismus  has  disappeared. 

Stricture  of  the  Vagina. — Occlusion  of  the  vagina  may  be  ^ar^/aZ  or 
complete,  and  may  be  congenital  or  acquired.  The  diagnosis  is  readily 
made  by  digital  examination  or  by  inspection.  Imperforate  or  partially 
obliterated  hymen  need  not  be  mistaken  for  true  stricture,  when  it  is 
borne  in  mind  that  this  membrane  is  situated  just  at  the  entrance  to  the 
vagina,  while  stricture  proper  occurs  beyond  this  point  in  a  large  major- 
ity of  cases.  The  exact  situation  of  the  obstruction  may  be  readily  ap- 
preciated by  making  a  digital  exploration  of  the  rectum,  thus  locating 
the  cervix  uteri,  while  the  other  index-finger  is  introduced  per  naginam 
as  far  as  the  stricture.  In  complete  obstruction  {atresia),  the  absence  of 
the  menstrual  discharge  should  be  considered  in  arriving  at  a  diagnosis. 

Treatment. — In  partial  occlusion,  due  to  bands  or  a  membrane,  these 
should  be  divided  or  ruptured,  a  thorough  dilatation  accomplished,  and 
the  glass  cylinder  of  Dr.  J.  Marion  Sims  introduced,  as  in  the  treatment 
of  vaginismus.     When  there  is  a  narrowness  of  this  canal,  without  well- 


760 


A  TEXT-BOOK  ON   SURGERY. 


marked  contracting  bands,  it  will  suffice  to  dilate  with  bougies,  gradu- 
ally increasing  in  size  until  a  cure  is  effected.  The  operation  may  be 
repeated  two  or  three  times  a  week,  or  less  frequently  should  any  severe 
inflammation  supervene. 

When  the  opening  is  so  small  that  the  finger  can  not  be  introduced,  a 
probe-pointed  bistoury  may  be  carried  through  and  the  obstruction 
divided  in  several  directions,  after  which  forcible  dilatation  should  be 
practiced. 

When  complete  occlusion  exists,  the  canal  should  be  ojDened  up  by 
cutting  through  the  adherent  walls  in  the  ascertained  direction  of  the 
cervis  uteri.  By  dilating  the  canal  as  wide  as  possible  to  the  point  of 
obstruction,  then  locating  the  cervix  with  the  index-finger  of  the  left 
hand  in  the  rectum,  and  the  sound  kept  constantly  in  the  urethra  and 
bladder  as  an  additional  guide,  the  dissection  may  be  safely  accom- 
plished. The  Sims  glass  cylinder  should  be  employed  in  the  after- 
treatment. 

Narrowing  the  Vagina. — As  a  result  of  over-stretching  during  labor, 
and  especially  when  the  perineal  body  has  been  ruptured,  the  posterior 
wall  of  the  vagina,  with  or  without  the  contiguous  wall  of  the  rectum  and 
the  anterior  wall  of  the  vagina,  with  the  bladder,  protrude  into  the 
vagina.  The  former  condition  is  known  as  rectocele,  the  latter  cystocele. 
The  uterus  and  its  appendages  are  also  more  or  less  dragged  down- 
ward, the  cervix  approaching  the  ostium  vagin(B  and  in  extreme  cases 
I)rotruding  between  the  Idtbia.— prolapsus  uteri. 

It  is  important  to  correct  each  or  all  of  these  conditions  at  the  earli- 
est possible  moment.  The  operation  for  the  cure  of  rectocele  consists  in 
removing  the  mucous  membrane  from  the  posterior  wall  of  the  vagina 
over  an  area  sufficiently  large,  and  then  introducing  sutures  of  silver 
wire  to  hold  the  freshened  surfaces  together  until  union  has  occurred. 
Since  rectocele  exists  so  frequently  with  laceration  of  the  perinseum,  the 
two  conditions  should  be  corrected  by  a  single  operation.     The  method 

of  procedure  for  partial  rectocele 
has  been  given  with  peringeor- 
raphy. 

The  extent  of  denudation  may 
be  determined  by  approximating 
the  sides  of  the  floor  of  the  vagi- 
na with  tenacula.  The  mucous 
membrane  shoiild  now  be  trimmed 
ofl"  with  sharp-pointed  scissors 
curved  on  the  flat.  The  freshened 
area  may  be  oval  in  shape,  as  in 
Fig.  665  H,  or  may  vary  to  suit 
any  particular  operation,  bearing 
in  mind  the  object  to  be  attained, 
namely,  a  uniform  narrowing  of 
the  tube  so  as  to  render  descent  of  the  uterus  or  rectal  wall  impossible. 
It  is  advisable  to  begin  the  denudation  at  the  vulva  and  work  upward, 


Fio.  665  H.— Oval  denudation  for  the  cure  of  recto- 
cele, ■with  sutures  passed.    (After  Thomas.) 


VESICO-YAGINAL  FISTULA.  761 

for  in  this  way  tlie  blood  does  not  obscnre  tlie  field  of  operation.  The 
mucous  membrane  may  be  rapidly  pared  off  by  lifting  the  posterior  wall 
of  the  vagina  forward  by  means  of  one  or  two  fingers  introduced  into  the 
rectum.  Sutures  of  silver  wire  are  next  introduced,  as  shown  in  Fig. 
665  H.  "While  this  is  being  done,  the  finger  should  be  kept  in  the  rec- 
tum, so  that  the  needle  may  not  enter  this  cavity.  On  account  of  the 
pain  caused  in  its  removal,  silver  wire  is  objected  to  by  some  operators 
and  chromicized  catgut  sutures  have  been  in  late  years  substituted. 
Properly  prepared,  these  sutures  will  hold  the  raw  surfaces  in  apijosi- 
tion  for  eight  or  ten  days  and  secure  good  union.  Greater  quiet  should 
be  demanded,  however,  than  is  necessary  when  wire  is  emjDloyed.  "When 
the  perinseum  is  torn  and  perinseorraphy  is  necessitated,  silver  sutures 
should  be  employed  for  this  part  of  the  operation. 

For  cystocele  a  similar  operation  is  performed  on  the  upper  or  ante- 
rior wall  of  the  vagina.  In  order  to  prevent  the  possibility  of  wounding 
the  urethra  or  bladder,  or  allowing  the  needle  to  enter  while  the  sutures 
are  being  inserted,  a  large  sound  should  be  kept  in  the  bladder  during 
the  operation.  When  rectocele  exists  with  a  cystocele,  associated  with 
partial  prolapse  of  the  uterus,  the  operation  on  the  posterior  wall  by  re- 
storing and  holding  the  uterus  in  its  proper  place  may  also  relieve  the 
cystocele.  Unless  this  latter  condition  exists  in  a  severe  form,  it  is  ad- 
visable to  await  the  result  of  the  operation  for  rectocele  before  operating 
on  the  anterior  wall. 

Vest  co-Vaginal  Fistula. — A  fistulous  opening  from  the  bladder  into 
the  vagina  may  be  surgical  or  accidental. 

In  order  to  secure  drainage  of  the  bladder  for  the  relief  of  chronic 
cystitis,  or  for  other  purposes,  kolpo-cystotomy  may  be  demanded.  Sec- 
tion of  the  bladder-wall  should  be  in  the  median  line,  and  should  as 
nearly  as  possible  bisect  the  triangle  formed  by  the  orifices  of  the  ureters 
and  urethra.  A  sound  introduced  into  the  bladder  should  be  employed 
to  make  prominent  the  floor  of  this  organ,  while  with  the  Sims  specu- 
lum, the  patient  being  in  the  Sims  position,  the  section  may  be  readily 
accomplished  by  a  long-curved  bistoury.  For  drainage  of  the  bladder 
by  this  method  the  T  rubber  tube  employed  in  supra-pubic  cystotomy 
should  be  used.  The  end  may  project  out  of  the  vulva  into  the  urinal. 
For  the  removal  of  calculi  so  large  and  hard  that  lithotrity  is  contra- 
indicated,  and  for  all  neoplasms  of  this  organ,  supra-piibic  cystotomy 
is  preferable. 

The  details  of  the  operation  do  not  differ  materially  from  those  in 
this  operation  on  males.  The  water-bag  for  lifting  the  bladder  is  placed 
in  the  rectum,  or  the  finger  in  the  vagina  may  sufficiently  lift  the  organ 
toward  the  pubes.  If  the  bladder  will  not  retain  enough  water,  pressure 
of  the  iirethra  against  the  pubic  arch  will  secure  retention. 

The  form  of  vesico-vaginal  fistula  most  difiicult  to  deal  with,  and 
therefore  of  greatest  surgical  interest,  is  that  which  follows  sloughing  of 
the  vesico-vaginal  septum  during  difficult  parturition.  Fortunately,  the 
increased  skill  of  the  accoucheur  and  the  -ndder  dissemination  of  practical 
knowledge  in  midwifery  have  greatly  diminished  the  number  of  cases. 


762 


A  TEXT-BOOK   ON   SURGERY. 


In  closing  a  fistula  here,  the  following  general  points  are  important : 
The  vagina  and  bladder  should  be  got  into  the  best  possible  condition 
by  rest  and  irrigation  of  these  organs  for  some  days  before  the  opera- 
tion. When  well-marked  bands  of  cicatricial  tissue  exist  in  the  neigh- 
borhood of  the  margins  of  the 
fistula,  these  should  be  divided, 
and  a  bulb  or  glass  tube  of  large 
size  should  be  introduced  to  keep 
the  vagina  distended.  This  cyl- 
inder should  be  worn  for  the  few 
days  preceding  the  operation. 
With  the  patient  in  the  Sims  po- 
sition and  a  large  Sims  speculum 
(Fig.  665  i)  introduced,  the  opera- 
tion is  commenced  by  paring  the 
edges  of  the  fistulous  opening.  This  is  done  by  curved  scissors  or  the 
bistoury,  the  former  being  preferable.  If  any  portion  of  the  sinus  is  left 
unfreshened,  the  wound  will  fail  of  union.  All  cicatricial  tissue  should 
be  dissected  away,  for  only  fairly  healthy  tissue  will  unite.  The  sec- 
tion extends  through  the  mucous  membrane  of  the  vagina  and  directly 
through   the   vesico-vaginal   septum,    beveling   this   down   to  hut  not 


Fig.  665 1. — Sims's  speculun 


Fig.  665  j.— Sims's  needle  forceps. 


tJirougTi  the  mucous  membrane  of  the  bladder.  The  sutures  should  next 
be  introduced,  the  needle  entering  one  fourth  of  an  inch  from  the  edge  of 
the  wound,  and  coming  out  so  as  not  to  include  the  mucous  membrane 
of  the  bladder.  Dr.  J.  Marion  Sims,  who  originated  this  operation, 
insists  that  the  sutures  should  be  close  together — from  one  eighth  to 
three  sixteenths  of  an  inch  apart.  The  sutures  are  of  the  best  silver 
wire,  No.  28  or  29,  and  are  carried  into  place  by  a  silk  loop  with  which 
the  needle  is  threaded.     When  the  wire  is  being  introduced,  in  order  to 


I E  (WAN  N  a>-CpiBB™teBr; 


Fio.  665  TS.. — Sims's  fork  for  approximating  the  silver  sutures  at  the  level  of  the  wound. 

prevent  the  suture  tearing  through,  it  is  advisable  to  use  the  fork  (Fig. 
665  K),  to  take  the  strain  off  the  soft  parts.  When  all  the  wires  are  in- 
troduced, the  margins  of  the  wound  are  approximated  by  gentle  traction 
on  the  two  ends  of  the  wire,  the  fork  is  carried  down  to  the  level  of  the 
wound,  and  the  wire  twisted  upon  this,  as  shown  in  Fig.  665  L.  The 
ends  are  clipped  about  three  quarters  of  an  inch  from  the  wound.     A 


CERVIX   UTERI. 


763 


Sims  sigmoid  catheter  or  a  soft  jS'elaton  catheter  should  be  secured  in 
the  urethra  and  bladder.  The  sntnres  are  removed  about  the  eighth 
day,  the  jiatient  being  in  the  same  position  as  for  the  operation. 

After  the  operation  the  patient  should  be 
kept  quiet  in  bed,  resting  by  preference  upon 
the  side.  The  urine  should  be  drawn  at  regu- 
lar intervals,  when  the  stationary  catheter  is 
not  employed. 

In  the  closure  of  recto-vaginal  fistulte  the 
same  operative  measures  are  indicated. 

Cervix  Uteri.  —  Lacerations  of  the  cervix 
may  be  classified  as  unilateral,  bilateral,  ante- 
rior, posterior,  and  stellate.  They  are  also 
complete  or  incomplete.  The  bilateral  variety 
is  most  frequent,  the  unilateral  next,  the  re- 
maining forms  being  comparatively  rare.  In  a 
complete  laceration,  the  tear  extends  through 
all  the  tissues  of  the  cervical  wall  into  the  va- 
ginal vault ;  the  incomplete  variety  extends 
into  but  not  through  the  wall  of  the  cervix. 

The  principal  indications  for  operative  inter- 
ference are,  pain,  constant  in  character,  either 
local  or  reflex,  hypertrophy  or  thickening  of  the 

tissues  of  the  cervix,  as  a  result  of  granulations  along  the  line  of  the 
laceration,  cystic  degeneration  of  the  cervix,  sterility  from  occlusion  of 
the  internal  os,  inability  to  carry  the  foetus  to  term,  etc.  The  danger  of 
epithelioma,  resulting  from  prolonged  irritation  of  a  fissured  surface, 
should  never  be  lost  sight  of.  The  preparation  of  the  patient  is  practi- 
cally the  same  as  for  any  other  operation  aboiit  the  rectum  or  genito- 
urinary organs.  When  the  narcosis  is  complete,  she  is  placed  in  the 
Sims  position  and  a  large  Sims  speculum  introduced.  The  vagina 
should  then  be  thoroughly  in-igated  with  l-to-3000  sublimate  solution, 
and  this  canal  and  the  cervix  thoroughly  cleansed.  A  strong  tenaculum 
should  now  be  hooked  securely  into  the  sound  portion  of  the  cervix  and 
the  uterus  drawn  toward  the  vulva.  A  second  tenaculum  is  firmly  in- 
serted at  the  edge  of  the  rent,  the  edge  of  which  is  now  trimmed  off 
with  the  Sims  adjustable  knife,  or,  if  this  is  not  at  hand,  Emmet's 
cervix-scissors.  In  freshening  the  edges  of  the  laceration,  the  section 
should  extend  thoroughly  into  the  angle  of  the  tear,  and  all  cicatricial  or 
granulating  surfaces  should  be  most  carefully  removed.  When  the  tis- 
sue along  the  line  of  the  tear  is  densely  cicatricial,  it  must  be  deeply 
excised  for  a  successful  union,  as  restoration  of  the  cervical  canal  can 
not  be  accomplished  when  the  cicatrix  remains. 

When  a  bilateral  laceration  exists,  the  denuded  area  should  extend 
well  out  to  the  vaginal  surface  of  the  cervix  and  inward  to  the  level  of 
the  internal  os,  or  remaining  cervical  canal.  It  is  usual  to  leave  unfresh- 
ened  a  space  of  about  one  foiirth  of  an  inch  wide,  as  shown  at  a  a.  Fig. 
665  M,  which  space  corresponds  to  the  canal  to  be  restored  by  the  opera- 


764 


A  TEXT-BOOK   ON  SURGERY. 


tion.  The  opposite  fissure  is  prepared  in  the  same  manner,  and  the  wire 
sutures  are  then  inserted.  The  most  suitable  needle  is  a  short,  strong 
needle  with  a  slight  cutting  edge  on  one  side,  this  cutting  edge  limited  to 
the  first  one  fourth  of  an  inch  from  the  point.  This  needle,  armed  with 
the  silk  which  serves  to  carry  the  wire,  is  passed  through  the  vaginal 
portion  of  the  cervix,  one  fourth  of  an  inch  from  the  edge  of  the  wound, 
and  brought  out  barely  within  the  undenuded  area  a  a  left  to  form 
the  walls  of  the  canal  (i,  i,  Fig.  665  m).     The  deep  suture— that  in  the 


Fig.  665  M.— Showing  the  area  of  denudation,  and  the  method  of  passing  sutures  in  bilateral  laceration 
of  the  cervb;.     (Munde.) 

angle— should  be  first  inserted.  When  .all  the  sutures  are  passed,  they 
should  be  twisted  in  the  order  of  insertion.  It  is  important  to  bring  the 
freshened  surfaces  accurately  together,  taking  care  not  to  twist  the  wire 
too  tight,  for  fear  of  strangulating  the  tissue  in  its  grasp. 

After  the  sutures  are  all  twisted,  they  should  be  cut  at  one  fourth  of  an 
inch  from  the  line  of  iinion  and  a  sound  introduced,  to  see  that  the  canal 
is  not  by  accident  occluded.  Whenever  this  is  too  narrow,  or  whenever 
for  any  reason  the  entire  mucous  membrane  of  the  cervical  canal  is  of 
necessity  removed,  a  glass  or  hard-rubber  stem  should  be  inserted  and 
worn  for  several  weeks,  until  the  walls  of  the  new  canal  shall  be  covered 
by  epithelium. 

The  patient  is  put  to  bed  and  kept  perfectly  quiet.  The  suture  may 
be  removed  on  the  eighth  or  tenth  day.  This  is  accomplished  by  plac- 
ing the  patient  in  the  same  position  as  for  operation,  cleansing  the  parts 
thoroughly,  lifting  the  deepest  suture  with  the  forceps  until  one  side  of 
the  deeper  and  diverging  wire  is  seen,  and  then  dividing  this  with  the 
sharp-pointed  wire  scissors.  Great  care  and  considerable  skill  are  neces- 
sary to  prevent  the  tearing  apart  of  the  freshly  united  surfaces.  The 
patient  should  remain  in  bed  for  a  week  or  ten  days  longer. 

Excision  and  Amputation  of  tlie  Cervix. — On  account  of  cystic  de- 
generation of  the  cervix,  or  for  the  removal  of  granulating  surfaces  of 
long  standing,  or  the  presence  of  epithelioma,  the  removal  of  a  portion 
or  all  of  this  part  of  the  uterus  may  be  required.  Excision  is  best  per- 
formed with  the  knife,  the  blade  of  which  should  be  long  and  slender 
(Fig.  665  n).  Securing  the  cervix  with  a  hook  fastened  near  the  ante- 
rior margin,  the  blade  is  carried  up  the  cervical  canal  to  a  point  high 


VAGINAL   HYSTERECTOMY. 


765 


enougli  to  reach  all  the  diseased  tissue,   then  forced  into  the  wall  a 
sufficient  depth,  and  is  carried  around  so  as  to  remove  a  cone-shaped 


Fig.  605  jr. — Sims's  adjustable  kniie-holder. 

mass,  the  center  of  which  is  the  old  canal  of  the  cervix.  The  walls  of 
the  shell  which  remains  should  now  be  brought  together  by  a  row  of 
silver-wire  sutures  on  either  side  (arranged  in  the  same  manner  as  for 
a  laceration),  leaving  a  roomy  canal  in  the  median  line  into  which  the 
stem  should  be  inserted  and  worn  until  an  ei^ithelial  lining  is  developed 
upon  the  surfaces  of  this  new  canal. 

When  a  more  extensive  excision  or  amq)utation  is  required,  proceed 
as  follows :  If  it  is  intended  to  remove  the  cervix  at  or  near  the  inter- 
nal OS,  it  should  be  seized  with  the 
tenaculum,   and  drawn  toward  the 
vulva  and  cut  squarely  off  with  the 


Fig.  fi6.5  o. 
The  stump  after  amputation  of  the  cervbc. 


Fig.  665  p.— Flaps  secured  by  sutures. 


scissors  or  knife.  If  considerable 
bleeding  occurs,  the  vessels  should 
be  immediately  secured.  The  con- 
tiguous vaginal  tissue  should  now  be  dissected  up,  and  wire  sutures 
inserted  on  either  side  of  the  canal,  so  that  when  tightened  the  vagi- 
nal tissues  are  drawn  over  and  form  a  covering  for  the  stump  (Figs. 
665  o  and  665  p). 

Vaginal  Hysterectomy. — For  incipient  malignant  disease  of  the 
uterus,  the  extirpation  of  this  organ  is  indicated,  and  this  may  be  done 
through  the  vagina  or  by  abdominal  section.  In  the  selection  of  a 
method  the  size  of  the  uterus,  as  a  result  of  the  neoplasm,  or  from  any 
cause  whatever,  should  be  carefully  considered.  If  this  organ  is  about 
of  normal  size,  vaginal  hysterectomy  properly  performed  offers  at  this 
date  a  lower  mortality  rate  than  the  high  operation. 

J.  B.  Hunter's  MetJiod*~ln  order  to  complete  the  hysterectomy 
more  rapidly,  forceps  are  applied  to  the  principal  vessels  and  bleeding 
points  as  the  operation  proceeds,  and  these  are  left  in  position  for  periods 


*  "  Medical  Record,"  February  9,  1889,  p.  147. 


766  A  TEXT-BOOK  ON  SURGERY. 

varying  from  twenty-four  to  forty-eight  hours  ;  the  time  otherwise  lost  in 
applying  ligatures  is  thus  materially  shortened.  The  patient  is  placed 
on  the  back,  the  sacrum  at  the  edge  of  the  table,  and  the  legs  held  up 
and  out  of  the  way  by  assistants  or  supported  by  the  crutch.  The  pel- 
vis may  be  slightly  elevated,  to  allow  gravitation  to  carry  the  intestines 
toward  the  diaphragm.  Irrigate  thoroughly  with  2-per-cent  creoline,  or 
l-to-5000  sublimate  solution.  A  large  Sims  speculum  and  lateral  retract- 
ors are  required,  and  the  uterus  is  drawn  well  downward  and  backward 
by  a  long  tenaculum.  With  curved,  blunt-pointed  scissors  the  dissection 
is  begun  at  the  junction  of  the  cervix  and  vagina  in  front,  keeping  a 
sound  in  the  bladder  all  the  time  to  avoid  the  danger  of  cutting  into  this 
organ.  Proceed  in  this  direction  until  the  peritonseum  is  reached,  but 
this  should  not  yet  be  opened.  Draw  the  uterus  forward  and  make  a 
similar  dissection  on  the  rectal  surface.  As  the  lateral  attachments  are 
next  to  be  separated,  it  is  necessary  to  proceed  very  cautiously,  using 
the  scissors  so  as  not  to  dividfe  much  tissue  at  a  single  stroke,  for  fear 
of  severing  the  larger  vessels.  When  these  are  reached,  the  forceps 
are  applied  and  the  tissues  divided  between  the  instrument  and  the 
uterus.  The  handles  of  the  forceps  should  be  tied  with  silk  to  prevent 
their  being  dislodged.  A  second  instrument  is  applied  beyond  the  first, 
and  secured  in  like  manner,  until  the  broad  ligament  of  each  side  is 
divided.  As  the  peritonseam  is  dissected  away,  by  traction  on  the  fun- 
dus uteri  the  utero-sacral  ligaments  may  be  put  on  the  stretch,  forceps 
applied  to  these,  and  the  ligaments  divided.  All  minor  bleeding  points 
should  be  secured  by  forceps,  and  many  of  these  may  be  removed  as  soon 
as  the  operation  is  over.  If  the  tubes  and  ovaries  come  plainly  into  view, 
they  should  be  tied  oii  with  strong  silk  and  removed.  The  uterus  being 
entirely  dissected  out,  is  readily  introverted  and  cut  off  at  the  vaginal 
junction.  The  parts  are  sponged  dry,  no  irrigation  employed,  the  for- 
ceps on  the  important  vessels  left  in  position,  the  entire  cavity  packed 
with  creoline  gauze,  the  pieces  of  which  are  attached  to  silk  threads  to 
facilitate  removal.  A  tuft  of  cotton  is  placed  around  the  handles  of  the 
forceps.  The  bladder  should  be  emptied  at  regular  intervals,  and  the 
bowels  moved  on  the  third  day  by  the  administration  of  calomel  tritu- 
rates, half  grain  doses,  repeated  three  or  four  times.  Some  of  the  for- 
ceps on  the  less  important  vessels  may  be  removed  after  twenty-four 
hours,  those  on  the  larger  arteries  in  from  thirty-six  to  forty-eight  hours. 
The  peritoneal  surfaces  unite  readily,  and  the  entire  wound  heals  by 
granulation. 

Irrigation  should  not  be  employed  earlier  than  the  third  day,  and 
fluids  should  not  be  forcibly  thrown  into  the  wound.  The  most  careful 
antisepsis  is  demanded,  both  during  the  operation  and  at  the  dressings. 

Hysterotomy  and  Abdominal  Hysterectomy. — Hysterotomy^  or  cut- 
ting into  the  uterus  for  the  extraction  of  the  foetus  from  the  living 
mother,  is  an  operation  which  has  been  greatly  perfected  within  the  last 
few  years,  chiefly  owing  to  the  labors  of  Saenger,  Leopold,  and  Tait.  It 
is  indicated  when  at  full  term  it  is  found  impossible,  on  account  of  in- 
surmountable disproportion  between  the  diameters  of  the  pelvic  outlet 


HYSTEROTOMY   AND   ABDOMINAL   HYSTERECTOMY.         767 

and  the  child,  to  effect  delivery  by  the  vagina.     When  this  condition  is 
evident,  proceed  as  rapidly  as  possible  in  the  following  manner : 

If  the  membranes  are  not  already  ruptured,  break  them.  Disinfect 
the  vagina  and  genitals  with  sublimate  solution,  l-to-3500.  Prepare  the 
abdomen  as  for  an  ovariotomy,  and  make  a  long  abdominal  incision, 
controlling  all  bleeding  with  catgut  ligatures  as  the  operation  proceeds. 
Having  entered  the  abdominal  cavity  and  made  the  opening  large 
enough,  place  three  or  four  silk  sutures  afc  the  upper  end  of  the  wound 
in  order  to  narrow  the  opening  as  soon  as  the  uterus  is  drawn  out  of 
the  incision,  thus  avoiding  extrusion  of  the  intestines.  Drag  the  uterus 
outside  the  abdominal  cavity,  and  close  the  upjDer  portion  of  the  wound 
by  tightening  the  sutures  akeady  in  position.  If  the  intestines  should 
be  protruded,  protect  them  with  warm  towels  wrung  out  of  Thiersch's 
solution,  and  beneath  the  uterus  pass  a  piece  of  rubber  cloth,  disinfected 
in  the  same  solution,  to  protect  the  abdominal  cavity  from  the  entrance 
of  blood.  Around  the  cervix  uteri  pass  a  stout  piece  of  elastic  tubing, 
and  draw  it  tight,  thus  arresting  the  circulation  in  the  uterus.  Immedi- 
ately incise  the  uterus  in  the  median  line  and  in  its  long  axis,  limiting 
the  incision  below  to  the  peritoneal  reflection,  thus  avoiding  the  large 
circular  sinuses  about  the  os  internum,  and  extending  it  ujjward  if  neces- 
sary. Eemove  the  child,  and  hand  it  to  an  assistant  to  resuscitate.  The 
uterus  will  now  usually  contract.  Introduce  the  hand  into  the  uterus 
and  remove  the  placenta.  The  uterine  cavity  is  next  to  be  disinfected 
with  a  l-to-5000  sublimate  solution.  Unless  the  cervical  canal  is  widely 
dilated  (a,nd  this  should  be  ascertained  before  the  operation),  the  use  of  a 
utero-vaginal  drainage-tube  is  indicated,  and  this  latter  must  be  of  stiflf 
rubber.  The  next  step  in  the  operation  is  the  insertion  of  the  sutures  in 
the  wall  of  the  uterus.  First  ascertain  whether  the  peritoneal  covering 
of  this  organ  is  siifficiently  movable  to  allow  it  to  be  folded  in  between 


-f-    Mucosa. 


Fio.  665  Q. — Sutures  in  Csesavean  section.  Method  of  passins;  tlie  sutures  in  closine:  the  wall  of  the  uterus 
after  hysterotomy,  a,  The  peritoneal  coverinsr  dissected  up  along  the  edge  of  the  incision  and  in- 
verted by  the  catgut  suture,  after  the  method  of  Lembert.  b.  The  muscular  substance,  with  the 
silvei^wire  suture  passed  tnrough.     c,  Decidua.     (Drawn  by  Dr.  W.  K.  Pryor.) 

the  sides  of  the  incision.  If  need  be,  dissect  it  up  from  its  attachment  to 
the  muscular  fibers  a  slight  distance.  The  peritonjBum  is  next  folded  in 
between  the  lips  of  the  woimd,  and  the  deep  sutures  are  passed  (Fig. 
665  q).  These  should  be  of  silver  wire,  because  they  are  cleaner  and  held 
more  unyieldingly  than  silk.     They  should  be  close  enough  to  control 


768  A  TEXT-BOOK  ON  SURGERY. 

liEemorrhage  and  secure  accurate  adjustment  of  the  sides  of  the  wound 
They  should  enter  the  ijeritoneal  covering  about  half  an  inch  from 
the  edge  of  the  wound,  and  pass  through  it  and  the  muscular  wall  to 
the  decidua,  which  must  not  be  included  in  the  suture ;  then  across 
to  the  other  side  through  the  muscular  and  serous  coats.  After  twist- 
ing the  silver  sutures,  the  superficial  sutures  of  fine  silk  are  intro- 
duced. These  are  to  be  from  twenty  to  thirty  in  number,  and  are  em- 
ployed to  secure  perfect  coaptation  of  the  serous  edges  of  the  incision. 
They  are  introduced  in  the  same  way  as  Lembert's  suture  of  the  intes- 
tine. Lastly,  the  twisted  silver  wires  are  cut  oif  about  one-half  inch 
from  the  level  of  the  incision  in  the  uterus,  and  the  ends  turned  down 
parallel  with  the  surface  of  this  organ. 

The  incision  in  the  abdominal  wall  is  closed,  as  after  ovariotomy. 
There  are  certain  conditions  which  can  only  be  determined  by  inspec- 
tion through  the  incision  in  the  abdominal  wall  which  may  contraindi- 
cate  the  operation  just  given,  and  necessitate  a  modified  procedure. 

If  the  patient  has  been  long  in  labor,  and  considerable  time  has 
elapsed  after  the  membranes  have  ruptured  ;  if  there  is  a  putrid  dis- 
charge from  the  vagina  ;  if  the  symptoms  of  septic  fever  are  present, 
with  the  perimetrium  dulled  and  adherent  to  the  muscular  wall  of  the 
uterus,  the  operation  of  amputation  of  the  uterus  at  the  os  internum 
is  indicated.  If  malignant  disease  of  the  cervix  is  present,  Freund's 
operation  is  to  be  preferred.  If  the  pregnant  uterus  be  the  seat  of  a 
fibro-myoma,  and  so  situated  as  to  render  delivery  impossible,  or  if  a 
rupture  of  the  walls  of  the  uterus  has  occurred,  which  is  so  ragged  in 
outline  that  it  can  not  be  sutured,  hysterectomy  is  indicated.  The 
objects  aimed  at  in  all  operations  for  the  artificial  delivery  of  children 
at  term  are,  preservation  of  the  mother's  life  and  future  health,  with, 
if  possible,  the  non-mutilation  of  her  generative  organs  and  the  delivery 
of  a  living  child.* 

Porro's  Operation.^ — Hysterectom,y  during  Pregnancy. — The  abdom- 
inal incision  is  similar  to  that  just  given.  It  must  not  be  overlooked  that 
the  bladder  is  high  up  and  in  good  part  uncovered  by  the  peritonseum. 
As  soon  as  the  uterus  is  exposed  it  should  be  drawn  out  of  the  abdomen. 
Place  around  the  cervix  a  large  piece  of  rubber  tubing  if  an  ecraseur  or 
clamp  is  to  be  used  ;  or  a  rubber  ligature,  if  that  is  to  be  permanent.  Pro- 
tect the  intestines  with  warm  towels  wet  in  Thiersch's  solution.  Under 
the  uterus  and  over  the  abdominal  incision  spread  a  large  piece  of  rubber 
cloth,  protecting  the  peritoneal  cavity  from  the  entrance  into  it  of  blood, 
etc.  Tighten  the  rubber  ligature  around  the  cervix,  and  immediately  in- 
cise the  uterus  and  rapidly  extract  the  child.  The  incision  in  the  uterus 
may  be  made  in  any  direction  convenient,  although,  as  a  rule,  the  median 
linear  incision  is  preferable.  The  next  step  is  to  cut  off  the  uterus  close  to 
the  ligature.  Curette  out  the  cervical  canal,  or  burn  it  and  the  stump 
with  the  cautery.     Cleanse  the  peritoneal  sac  of  blood  and  serum.     See 

*  As  regards  statistics,  Saenger  gives  thirty  Csesarean  sections  performed  as  above  de- 
scribed, with  a  mortality  of  26'7  per  cent. 

t  The  mortality  after  this  operation  is  greater  than  that  after  hysterotomy. 


HYSTERECTOMY.  769 

that  no  blood  has  collected  between  the  cervix  and  pubes.  Transfix  the 
stnmp  with  long  steel  pins  jiist  above  the  ligature,  and  otherwise  treat 
the  stump  as  should  be  done  after  hysterectomy  for  tibro-myomata.  If 
it  is  deemed  necessary  to  employ  drainage,  the  Sims  tube  (see  Pig.  667) 
should  be  employed  in  these  cases.  The  stump  should  be  dusted  with 
iodoform,  as  heretofore  directed. 

The  method  recommended  by  Tait  is  practically  as  follows :  An  ab- 
dominal incision  is  made  large  enough  to  admit  the  hand.  A  piece  of 
strong  rubber  tubing  is  thrown  around  the  uterus  near  the  vaginal  junction 
and  tightened  to  arrest  the  circulation.  An  oj)ening  partly  by  incision 
and  tearing  is  next  made  in  the  median  line  and  long  axis  of  the  uterus, 
through  which  the  child  and  then  the  placenta  are  extracted.  The  organ, 
rapidly  contracting,  is  brought  out  through  the  wound,  transfixed  with 
two  skewers  just  above  the  rubber  cord,  and  the  amputation  made.  After 
a  careful  toilet  of  the  peritoneal  cavity  the  wound  is  closed,  the  cord 
being  left  in  position,  and  the  stump  stitched  to  the  edges  of  the  incision. 
When  a  simple  hysterotomy  is  intended,  the  oisening  in  the  uterus 
should  be  incised,  not  torn,  and  sutures  applied  as  directed  in  the  pre- 
ceding page. 

FreuncPs  Operation. — Removal  of  the  uterus  for  malignant  disease 
of  this  organ  is  thus  performed  :  The  patient  is  prejDared  as  for  an  ovari- 
otomy. The  vagina  is  cleansed  and  rendered  aseptic.  The  abdomen  is 
opened,  the  uterus  found  and  drawn  up  to  the  incision.  It  is  then  pulled 
to  one  side,  and  the  broad  ligament  of  the  opposite  side  ligated  in  such  a 
way  that  the  ovarian  artery,  Falloj^ian  tube,  and  round  ligament  are  in- 
cluded in  the  grasp  of  the  ligature.  The  ligament  of  the  other  side  is  in 
the  same  way  tied  oif.  The  uterine  arteries  are  next  deligated  by  means 
of  a  ligature  passed  through  the  fornix  vaginse.  If  it  be  desired  to 
remove  the  entire  organ,  the  bladder  is  separated  from  the  cervix,  and 
the  tissues  around  the  cervix  are  cut  through.  Freund  originally  left 
the  ligatures  long,  and  brought  them  out  of  the  vaginal  opening.  If  it  is 
desired  to  make  a  stump  of  the  cervix,  as  in  the  case  of  cancer  of  the 
fundus  uteri,  the  uterus  is  cut  off  just  above  the  utero-vaginal  junction, 
the  two  lips  of  the  cervix  brought  together  with  deep  sutures,  the  peri- 
tonaeum carefully  adjusted  over  them,  the  ligatures  cut  short,  and  the 
peritoneal  cavity  closed. 

Hysterectomy  for  the  Removal  of  Flhro-myomata — Scliroedef  s  Op- 
eration.— After  opening  the  abdomen  the  uterus  and  fibroids  are  freed 
from  adhesions.  A  temporary  elastic  ligature  is  tied  around  the  cervix, 
and  the  tumors  and  uterus  cut  away,  leaving  the  stump  in  the  shape  of 
a  V.  The  blood-vessels  are  now  ligated  with  catgut  (Schroeder  does  not 
insist  ujDon  this),  and  the  sides  of  the  cone  brought  together  by  layers  of 
close  sutures  which  begin  at  the  bottom  of  the  cavity.  This  mode  of 
suturing  is  continued  until  the  top  is  reached,  when  the  peritonaeum  is 
carefully  adjusted  over  the  stump  and  the  elastic  ligature  removed.  Or 
the  pedicle  may,  if  small,  be  transfixed,  ligated,  and  dropped.  The 
peritongeum  is  cleansed  of  blood,  etc.,  and  the  abdomen  closed.  If  the 
myoma  is  pedunculated  and  the  uterus  itself  is  not  the  seat  of  multiple 

49 


770 


A  TEXT-BOOK   ON  SURGERY. 


growths,  the  tumor  is  cut  off,  and  the  suturing  done  at  the  point  where 
the  tumor  grew.  Or,  if  the  tumor  is  sessile,  so  that  the  elastic  ligature 
can  not  be  employed,  it  is  advised  to  incise  the  cajDsule,  enucleate  the 
tumor,  and  bring  the  flaps  together  as  above  directed.  Keith  and  Hegar 
have  the  smallest  mortality  after  hysterectomy,  and  it  is  their  custom  to 
treat  the  pedicle  by  the  extra-peritoneal  method.  But  there  are  tumors 
which  can  not  be  so  treated  ;  these  Schroeder  enucleates  as  described. 

Hysterectomy  for  Flhro-myoma  ;  the  Stump  being  brought  out  at  the 
Wound  and  attached  there. — After  the  organ  is  exposed  and  all  adhe- 
sions tied  with  double  ligatures  and  divided  between  these,  or  broken 
loose  where  the  double  ligature  can  not  be  utilized,  the  elastic  liga- 
ture should  be  thrown  around  the  uterus  at  the  cervix,  the  rubber  pass- 
ing under  the  ovaries  and  compressing  the  broad  ligament  against  the 
cervix.  This  ligature  is  drawn  tight  and  tied,  the  second  part  of  the 
knot  being  over  a  coarse  silk  thread.  AVhen  the  last  knot  of  the  elastic 
ligature  is  made,  the  silk  thread  is  tied  around  this  to  prevent  slipping. 

The  fibroid  is  then  held  up  and  cut  off  above  the  elastic  ligature. 
The  stump  is  next  grasped  by  strong  forceps  and  trimmed.  Sutures  are 
then  passed,  first  through  the  parietal  peritonaeum  near  the  incision  and 
then  through  the  stump  below  the  ligature,  in  such  a  v/ay  that  when 
drawn  tight  the  lower  part  of  the  incision  will  surround  the  stump  just 
below  the  ligature,  with  the  peritoneal  surface  of  the  incision  fastened 
to  that  of  the  stumj?.  Steel  pins  or  skewers  should  be  passed  through 
the  stump  above  the  ligature.     The  sutures  around  the  stump  are  then 

drawn  tight,  the  wound  closed  as  after 
ovariotomy,  the  stump  dusted  freely 
with  iodoform,  and  the  di'essing  applied. 
When  the  sutures  are  all  inserted,  the 
hard-rubber  plates  or  shields  (Fig.  665  r) 
should  be  placed  between  the  ends  of 
the  skewers  and  the  skin.  The  indica- 
tions for  pelvic  drainage  will  be  the 
same  as  after  an  ovariotomy.  The  cer- 
vical canal  in  the  stump  should  be  cu- 
retted before  passing  the  steel  pins ; 
otherwise,  a  fistulous  opening  may  per- 
sist through  the  vagina,  uterine  stump, 
and  the  line  of  incision.  Frequently  the  fibroid  is  attached  to  the  un- 
enlarged  uterus,  and  has  a  narrow  pedicle.  In  such  a  case,  the  uterus 
and  appendages  are  left,  and  the  new  growth  removed,  forming  the 
stump  where  the  tumor  joined  the  uterus. 

Surgical  Diseases  of  the  Fallopian  Tubes— Salpingitis.— ItA&vamvi- 
tion  of  the  Fallopian  tubes  may  demand  surgical  interference  when  peri- 
tonitis is  precipitated,  or  when  from  occlusion  the  products  of  inflamma- 
tion are  retained,  and  the  tube  is  distended,  forming  a  cyst- like  tumor. 

The  most  prominent  symptom  of  salpingitis  is  pain.  When  perito- 
nitis does  not  exist,  it  is  confined  to  the  affected  side.  It  is  usually  con- 
tinuous, with  exacerbations  of  severity,  which  are  especially  marked  just 


Fig.  665  R. — Sims's  skewer-sMelds. 


SALPINGITIS.  771 

before,  daring,  and  after  tlie  menstrual  flow.  In  some  instances,  wheii 
the  flow  is  established,  the  suffering  is  less  intense.  The  menstrual  dis- 
charge is,  as  a  rule,  increased  in  quantity.  Salpingitis,  in  the -vast 
majority  of  cases,  results  from  the  direct  extension  of  some  inflamma- 
tory process  from  the  uterus.  Endometritis  or  metritis  following  gonor- 
rhoea, abortion,  normal  parturition,  or  that  resulting  from  a  chronic  in- 
flammation due  to  malposition  of  this  org?^n  or  other  cause,  are  the  chief 
conditions  which  precede  this  affection. 

By  direct  palpation  over  the  abdomen  of  the  affected  side,  it  will  be 
seen  that  the  muscles  of  this  side  are  abnormally  tense,  and  that  acute 
pain  is  present  confined  to  a  limited  and  well-marked  area,  which 
corresponds  to  the  normal  position  of  the  tube.  In  the  vagina,  a  leu- 
corrhcEal  discharge  is  usually  observed,  and  diligent  examination  wiU 
reveal  great  tenderness  near  the  cervix,  upon  the  side  iavolved.  The 
uterus  may  be  normally  situated,  but  is  laterally  displaced  when  the 
tumor  is  at  aU  large.  AVith  bimanual  examination,  often  necessary  under 
ether,  there  will  be  found  an  elastic,  if  not  fluctuating,  tumor,  springing 
from  one  or  the  other  uterine  cornu,  and  directly  attached  to  the  uterus ; 
perhaps  bulging  into  the  vagina  ;  sausage-shaped  when  moderately  large, 
but  round  when  as  large  as  an  orange  ;  often  movable,  but  almost  always 
with  false  attachments.  This  tumor  may  be  biit  a  part  of  a  general  inflam- 
matory mass  filling  up  the  pelvic  cavity  and  rendering  fluctuation  hard 
to  obtain.  In  such  a  case,  the  uterus  is  flxed  to  this  mass.  As  a  rule, 
the  tube  is  prolaj)sed,  and  drags  with  it  the  ovary,  the  latter  being  exter- 
nal to  and  above  the  cyst.  In  many  cases  the  diagnosis  is  easy,  but  in 
others  it  is  difficult. 

Treatment. — When  the  diagnosis  is  satisfactorily  determined,  and 
the  symptoms  are  urgent,  removal  by  abdominal  section  is  indicated. 
The  preparation  of  the  patient  and  for  the  operation  are  the  same  as  for 
ovariotomy.  When  the  peritonseum  is  opened,  the  tumor  may  be  dis- 
tinctly felt,  and  should  be  removed  without  rupture  of  the  cyst-wall 
when  this  is  possible.  Adhesions  to  the  neighboring  organs  will  be  found 
to  exist,  in  a  varying  degree,  in  all  cases.  Some  of  these,  which  are  vas- 
cular and  of  good  size,  require  to  be  tied  with  double  large-sized  catgut 
ligatures  and  divided,  while  others  may  be  torn  off.  The  silk  ligature 
should  be  passed  around  the  tube,  close  to  the  surface  of  the  uterus,  tied, 
and  the  mass  removed.  The  stump  beyond  the  ligature  should  be  care- 
fully disinfected  and  seared  with  the  actual  cautery.  If  rupture  should 
occur,  or  if  there  is  a  considerable  amount  of  oozing,  the  Sims's  drainage- 
tube  should  be  used. 

The  Ovaries. — Removal  of  the  ovaries  may  be  necessitated  on  account 
of — 1,  cystic  degeneration  ;  2,  cirrhosis  ;  3,  abscess  ;  4,  cystic,  and  5,  solid 
tumors. 

In  cystic  degeneration  the  ovary  is  enlarged,  and  the  interior  of  the 
organ  is  filled  with  small  cysts  with  dense,  fibrous  capsules.  They  can 
in  some  cases  be  seen  through  the  iavesting  membrane,  and,  if  punct- 
ured, will  give  exit  to  a  fluid  usually  clear,  but  at  times  brown,  or  even 
decidedly  stained  with  blood.     The  tumor  is  elastic  to  the  touch,  usually 


772  A  TEXT-BOOK   ON   SURGERY. 

si^herical,  and  rarely  attaining  as  much  as  a  diameter  of  two  inches. 
The  fimbriated  extremity  of  the  Fallopian  tube  is  often  adherent  to  the 
diseased  ovary.  In  rare  instances  the  broad  ligament  and  tube  may 
surround  the  cystic  tumor.  The  left  organ  is  affected  more  frequently 
than  the  right,  for  the  same  reasons  as  given  for  the  more  frequent  oc- 
currence of  varicocele  in  the  left  scrotum  (see  Yaeicocele).  The  pa- 
thology of  this  affection  is  not  yet  definitely  settled. 

In  cirrTiosis  the  ovaries  are  usually  smaU,  and  have  a  furrowed  or 
withered  appearance  ;  occasionally  they  are  found  normal  in  size,  or  even 
slightly  enlarged.  The  normal  Graafian  follicles  are  entirely  destroyed 
in  well-marked  cases. 

In  more  recent  cirrhotic  disease  of  these  organs  the  cavities  of  the 
follicles  are  distended  with  a  bloody  fluid.  This  condition  is  almost 
always  due  to  a  connective-tissue  hyperplasia,  resulting  from  a  subacute 
inflammatory  j^rocess  in  the  ovary. 

In  abscess  of  this  organ  it  is  enlarged,  and  may  contain  one  cavity  or 
several  sei)arate  collections  of  pus.  When  the  abscesses  are  small  and 
multiple,  the  gross  appearances  of  the  organ  are  not  unlike  those  of  an 
ovary  with  cystic  degeneration.  Suppurating  salpingitis  (or  pyo-salpinx) 
may  be  present  with  abscess  of  the  ovary,  and,  in  rare  instances,  by 
reason  of  fusion  and  rupture  of  the  contiguous  walls,  there  results  a 
large  single  abscess.  Multiple  extravasation  of  blood  may  occur  in  ab- 
scess of  this  organ.  If  not  relieved  by  operation,  the  pus  may  eventually 
find  an  exit  through  the  vagiua,  bladder,  or  intestine.  Adhesions,  as  a 
rule,  occur  between  the  ovary  and  one  or  more  of  the  contiguous  organs, 
or  to  the  pelvic  fascia. 

Symptoms. — In  cystic  degeneration  and  cirrTiosis,  dysmenorrhoea  is 
the  most  prominent  symptom.  It  is  more  severe  with  the  former,  but  is 
severe  in  the  cirrhotic  ovary.  The  pain  usually  precedes  the  menstrual 
flow  from  a  few  hours  to  several  days,  and  in  extreme  cases  may  continue 
from  one  period  to  the  next.  It  is  usually  referred  to  the  groia  of  the 
affected  side,  and  thence  the  ipainful  sensations  may  radiate  over  the  abdo- 
men and  down  the  extremity.  Hysterical  convulsions  are  very  apt  to  be 
present  in  the  more  severe  cases.  The  menstrual  flow  is  scanty  or  normal 
in  amount  when  the  ovaries  are  cirrhotic  ;  but  with  cystic  degeneration 
the  flow  is  generally  increased,  and  haemorrhage  may  be  the  most  promi- 
nent and  dangerous  symptom.  The  uterus  is  ai^t  to  be  slightly  above 
the  normal  size,  with  the  ovaries  in  cystic  degeneration,  and  somewhat 
smaller  when  these  organs  are  cirrhotic.  Not  infrequently  retroversion 
is  obsei'ved  as  a  symptom  of  cystic  ovary,  in  which  case  this  last-named 
organ  is  prolapsed.  The  uterus  is  commonly  free  and  movable,  unless 
hgematocele  or  peritonitis  has  occurred.  If  cystic,  the  ovary  is  easily 
felt,  often  low  down  in  Douglas's  pouch.  If  cirrhotic,  it  is  hard  to  find. 
From  clinical  manifestations  it  ajjpears  that  cystic  degeneration  is  due 
to  a  degree  of  inflammatory  action  more  severe  than  that  which  leads  to 
cirrhosis,  because  peritonitis  and  pelvic  hgematocele  more  often  accom- 
pany the  former.  Cystic  and  cirrhotic  ovaries  are  always  sensitive  to 
pressure. 


SALPINGITIS.  773 

In  oriarian  abscess  there  is  usually  a  history  of  gonorrhoea,  puerperal 
septicaemia,  an  acute  exanthema,  or  a  severe  attack  of  metritis  or  peri- 
tonitis. When  the  abscesses  are  small,  the  symptoms  do  not  greatly 
differ  from  those  of  cystic  ovaries  ;  but  when  at  all  large,  the  patient 
has  hectic  fever  and  rigors.  The  jDain  in  the  pelvis  is  constant,  but  is 
liable  to  exacerbations.  Repeated  attacks  of  pelvic  peritonitis  follow 
each  other.  When  the  ovary  is  converted  into  one  large  abscess,  and 
the  tube  is  not  affected,  dysmenorrhoea  is  not  a  constant  symiatom,  and 
there  is  an  absence  of  the  nervous  phenomena  observed  in  the  other 
forms  of  ovarian  inflammation. 

The  uterus  is  usually  drawn  to  the  affected  side  as  a  result  of  the 
pelvic  peritonitis  which  usually  accompanies  these  cases.  The  lateral 
fornix  of  the  vagina  is  encroached  upon  when  the  abscess  is  large,  and 
then  fluctuation  can  be  obtained.  The  abscess,  whether  large  or  small, 
is  usually  but  part  of  the  mass  of  inflamed  tissue  which  occupies  the 
pelvis  on  the  affected  side.  The  ovary  is  enlarged  and  low  down.  As 
abscess  of  the  ovary  does  not  often  occur  alone,  and  as  the  sole  lesion 
of  the  pelvic  organs  and  tissues,  the  symptoms  which  appear  are  partly 
due  to  the  intercurrent  diseases — salpingitis,  hsematocele,  peritonitis,  etc. 
When  an  ovarian  abscess  ruptures  into  the  peritoneal  cavity,  a  fatal 
general  peritonitis  is  the  result.  If  it  opens  into  the  vagina,  it  usually 
does  so  Just  below  the  cervix  in  the  posterior  wall,  at  the  bottom  of 
Douglas's  pouch,  where  the  vaginal  wall  is  thinnest. 

Treatment. — If  the  ovarian  abscess  is  but  part  of  a  jpelvic  inflam- 
mation which  unites  together  rectum,  bladder,  uterus,  and  broad  liga- 
ment into  one  mass,  and  if  the  abscess  is  low  down,  fluctuation  being 
obtained  in  the  vaginal  roof,  it  may  be  opened  per  vaginam  and 
drained.  But  in  cases  of  pelvic  abscess  it  is  better  to  try  to  remove 
them  by  abdominal  section.  Exploratory  incision  has  but  little  mor- 
tality. A  certain  and  positive  knowledge  of  the  condition  of  the  parts 
in  these  cases  can  be  obtained  by  abdominal  section  only,  and  by  it  only 
can  a  radicalcure  and  extirpation  of  the  abscess  be  effected.  These  are 
the  most  difiicult  cases  the  surgeon  has  to  deal  with,  especially  when 
associated  Avith  pyo-salpinx  or  hsematocele.  The  draiaage-tube  should 
be  employed  whenever  rupture  of  the  abscess  occurs  in  the  efforts  at 
removal,  and  when  there  is  much  oozing  after  the  adhesions  are  broken 
up.  The  operation  is  similar  in  its  technique  to  that  of  removal  of  the 
tubes.  Cystic  and  cirrhotic  ovaries  are  to  be  removed  by  abdominal  sec- 
tion when,  aU  conservative  measures  having  failed,  the  patient's  health 
or  reason  is  seriously  threatened.  The  objection  of  sterility  can  not  be 
maintained,  for  these  women  are  already  sterile.  The  operation  may  also 
be  performed  in  cases  of  acute  mania  and  epilepsy  which  appear  to  be 
due  to  ovarian  disease  and  which  are  incurable  by  other  means.  The 
operation  is  simple.  An  incision  large  enough  to  admit  two  fingers  is 
made  in  the  median  line.  The  lower  angle  of  this  wound  should  be 
about  two  inches  above  the  os  pubis.  The  ovary  and  tube  are  freed 
from  false  attachments,  brought  toward  the  incision,  and  the  broad  liga- 
ment transfixed  close  to  the  uterus  with  a  double  ligature.   The  ligatures 


'j'74  A  TEXT-BOOK   ON   SURGERY. 

are  crossed— one  is  tied  above  the  tube  close  to  the  uterus,  the  other 
below  the  ovary  ;  the  tube  and  ovary  cut  off,  and  the  ligatures  cut  short. 
The  abdominal  wound  is  closed  as  heretofore  given.  Drainage  is  rarely 
indicated. 

Large  Cystic  Tumors  of  the  Ovary  and  Broad  Ligaments.— Cjstia 
tumors  of  the  ovary  are  occasionally  unilocular.  In  the  vast  majority  of 
instances  they  are  multilocular.  The  pathology  and  pathogenesis  of  these 
neoplasms  are  not  yet  definitely  settled,  and,  since  a  discussion  of  the  va- 
rious theories  advanced  is  scarcely  permissible  in  a  text-book,  the  student 
is  referred  to  the  various  standard  works  upon  pathology. 

The  most  common  form  of  ovarian  tumor— the  cyst-adenoma— is  al- 
ways multilocular.  The  surface  of  such  a  tumor  is  glossy,  often  silver- 
white.  The  sac  is  usually  firm,  its  contents  being  a  thick  fluid,  with  a 
grayish-brown  or  reddish  tint.  The  outline  of  the  cyst  may  be  perfectly 
symmetrical  and  round  ;  or  it  may  have  one  main  cyst,  and  numbers  of 
smaller  ones  springing  from  it ;  or  two  or  three  cysts  of  about  equal  size 
may  constitute  the  entire  mass.  But,  be  the  shape  what  it  may,  second- 
ary cysts  will  always  be  found  in  some  part  of  the  tumor.  At  one  or 
more  points  the  cyst- wall  may  be  exceedingly  thin  or  softened  as  a  re- 
sult of  the  rupture  of  inter-cystic  walls,  those  of  the  secondary  cysts 
being  thinner  than  that  of  the  lai'ger.  Softening  of  the  wall  may  also 
occur  when  the  neox^lasm  is  malignant ;  or  as  a  result  of  interference 
with  its  nutrition  from  twisting  of  the  pedicle ;  or  from  suppuration 
in  the  cyst-wall.  In  exceptional  instances  in  old  cysts  there  some- 
times exists  a  communication  between  the  cyst-cavity  and  the  bowel 
or  bladder  as  a  result  of  necrotic  changes  where  the  two  have  become 
adherent. 

In  size  cysto-adenomata  of  the  ovary  may  vary  from  a  few  inches  in 
diameter  up  to  those  of  enormous  size,  weighing  many  pounds,  and 
filling  the  entire  abdomen.  The  veins  lie  both  superficially  as  distinct 
vessels  and  deeiDly  in  the  cyst-wall  as  sinuses ;  the  arteries  are  more 
deeply  situated  and  are  large.  This  tumor  may  be  generally  adherent 
to  the  peritonteum  and  other  organs  with  which  it  comes  in  contact,  or 
connected  at  various  points  by  isolated  bands.  In  rarer  instances  no 
adhesions  may  be  met  with.  The  pedicle  of  an  adeno-cystoma  may  be 
attached  to  both  sides  of  the  uterus,  two  distinct  tumors  having  met  and 
coalesced.  At  times  the  tumor  derives  its  nourishment  from  bands  unit- 
ing it  to  the  abdominal  parietes  or  viscera,  its  own  pedicle  having  been 
twisted  off. 

A  form  of  multilocular  cyst,  connected  with  the  ovary,  known  as 
'■^BokitansJcy^s  tumor,"  has  been  observed  in  a  few  instances.  It  consists 
of  a  series  of  cysts  containing  a  clear  fluid.  The  cysts  hang  in  bunches 
and  are  connected  with  each  other  by  delicate  fibrous  bands.  The  entire 
mass  does  not  usually  reach  a  size  larger  than  the  fist. 

Dermoid  cysts  are  not  altogether  infrequent  in  the  ovary.  These  tu- 
mors have  thick  walls,  are  dark-colored,  are  filled  with  a  dark  fluid  in 
which  are  found  particles  of  hair,  teeth,  bone,  etc.  They  may  be  mul- 
tilocular, or  they  may  contain  but  one  cyst. 


SOLID    TUMORS.  775 

Hanging  frona  the  fimbriated  extremity  of  the  Fallopian  tube,  or  just 
beneath  it,  is  also  found  a  small,  thin- walled  cyst,  with  clear  contents, 
called  by  some  the  "hydatid  of  Morgagni."  If  examined  carefully 
while  it  is  floated  in  clear  water,  it  will  be  seen  to  be  a  continuation  of 
the  horizontal  tube  of  the  parovarium. 

Cyst  of  the  Broad  Ligament. — There  is  also  met  with  a  cyst  of  con- 
siderable size,  with  perfectly  clear  contents  and  very  thin  walls,  which  is 
sometimes  pedunculated,  but  generally  with  a  broad  attachment  located 
either  upon  the  broad  ligament  or  the  uterus.  A  small  cyst  of  a  simi- 
lar nature  may  spring  from  the  covering  of  the  Fallopian  tube  and  be 
pedunculated,  or  arise  just  beneath  the  FalloiDian  fimbriae,  and  be  either 
sessile  or  pedunculated. 

Solid  Tumors. — Fibro-myomata  appear  as  smooth,  firm  bodies.  They 
do  not,  as  a  rule,  contract  adhesions  with  neighboring  structures. 

Sarcomata  have  about  the  same  clinical  appearance,  except  when  very 
vascular,  in  which  state  they  are  softer  and  more  elastic  than  are  fibro- 
myomata.  Carcinomata  of  the  ovary  are  very  nodular,  and  when  large 
they  may  contain  one  or  more  cavities  in  their  interiors.  Secondary 
deposits  in  other  viscera  are  found  with  these  tumors.  The  symptoms  1 
of  all  solid  tumors  are  so  obscure  that  the  exact  character  of  any  of  these 
neoplasms  can  scarcely  be  determined,  excepting  by  microscopic  exami- 
nation. 

Symptoms. — Tumors  of  the  ovary  are  usually  first  noticed  upon  one 
side  of  the  pelvis.  The  ordinary  cysto-adenoma  is  not  painful  until  it  is 
so  large  that  it  presses  upon  the  pelvic  and  abdominal  viscera.  If  inflam- 
mation supervenes  from  any  cause,  j)ain  is  a  prominent  symptom.  Amen- 
orrhoea  is  the  rule,  although  in  a  certain  proportion  of  cases  men- 
struation is  normal.  Menorrhagia  is  rare.  If  left  without  interference, 
pressure  upon  and  displacement  of  the  neighboring  viscera  is  the  rule, 
and,  if  peritonitis  does  not  ensue,  death  ultimately  results  from  asthenia. 
Not  infrequently  adhesions  are  formed  between  the  bladder  and  the  neo- 
plasm to  such  an  extent  that,  as  the  tumor  grows,  the  bladder  is  dragged 
upward  to  the  neighborhood  of  the  umbilicus.  In  large  tumors,  dysp- 
noea, oedema  of  the  lower  extremities,  enlargement  of  the  superficial 
abdominal  veins,  and  nephritis  occur  as  a  result  of  pressure. 

Uj)on  examination,  it  is  usiially  easy  to  detect  the  presence  of  the 
tumor.  The  uterus  lies  in  front  of  the  cyst,  or  is  displaced  laterally  if 
the  tumor  be  large  enough  to  crowd  it  out  of  its  normal  position.  The 
iiterus  is  not  increased  in  size,  and  is  movable  independently  of  the 
neoplasm.  The  latter  is  an  important  feature  in  differentiation,  and 
may  be  best  determined  with  the  aid  of  the  elevator  carried  into  the 
uterus.  When  the  cyst  is  large,  the  uterus  is  dragged  high  up  and  fixed 
against  the  symphysis  pubis.  The  bladder  may  lie  over  the  front  of  the 
tumor  as  high  as  the  umbilicus.  But  when  the  tumor  is  so  large  as  to 
have  completely  risen  out  of  the  pelvis,  the  bladder  reaches,  even  when 
not  adherent  to  the  cyst,  a  point  somewhat  above  the  suprapubic  notch. 
The  enlargement  of  the  cyst  gives  to  the  abdomen  a  rotundity  not  seen 
with  distention  from  ascites  alone.     Ascites  commonly  coexists  with 


^^^^Q  A  TEXT-BOOK  ON  SURGERY. 

large  cysts.  If  not  large  and  non-adherent,  the  tumor  can  be  raised  out 
of  the  pelvis  without  the  uterus.  It  may  also  be  depressed  in  the  pelvis. 
When  the  secondary  cysts  are  large  and  project  from  the  surface  of  the 
main  cyst,  they  may  be  quite  readily  distinguished.  If  one  hand  is 
laid  flat  upon  one  side  of  the  mass  and  the  other  side  is  given  a  sharp 
tap  with  the  fingers,  the  fluid  character  of  the  contents  of  the  neoplasm 
may  be  easily  appreciated.  When  the  walls  of  the  tumor  are  very  thick 
and  the  distention  marked,  fluctuation  may  not  be  felt. 

In  solid  ovarian  neoplasms  pain  is  apt  to  be  present  early  in  the 
history  of  the  growth,  and  the  general  health  of  the  patient  may  show 
signs  of  deterioration  before  there  is  any  marked  increase  in  the  size  of 
the  tumor.     This  is  especially  true  of  malignant  new  formations. 

Fibro-myoma  of  the  ovary  is  so  often  associated  with  similar  changes 
in  the  uterus  that  the  slight  menorrhagia  which  occasionally  accompanies 
^hese  cases  may  reasonably  be  ascribed  to  uterine  hyperplasia.  Upon 
abdominal  palpation,  with  vaginal  exploration,  a  hard  and  usually  mov- 
able tumor  may  be  appreciated.  At  times  it  is  attached  to  the  surround- 
ing structures  to  such  an  extent  that  mobility  is  absent.  The  uterus  is 
not  enlarged,  is  often  displaced  backward,  and  is  generally  freely  mova- 
ble with  small  tumors.  AVhen  malignant,  the  tumors  are  of  rapid  growth. 
Ovarian  fibro-myoma  grows  slowly,  gives  little  pain,  never  immediately 
influences  the  general  health ;  is  generally  smooth,  or  vdth  but  a  few 
nodules  ;  not  very  sensitive,  and  is  usually  freely  movable  independently 
of  the  uterus.  Dermoid  tumors  may  appear  clinically  as  cystic  or  solid, 
according  as  their  fluid  or  solid  contents  predominate.  Adenocystomata 
and  dermoid  cysts  are  occasionally  met  with  in  young  children. 

Laparotomy  foe  the  Removal  of  Ttjmoes  of  the  Ovaky  and 
Fallopian  Tube. 

The  removal  of  a  tumor  of  the  ovary,  broad  ligament,  or  Fallopian 
tube,  cystic  or  solid,  is  performed  as  follows  : 

Preparation  of  the  Patient,  and  Operation. — For  several  days  be- 
fore the  operation  the  patient  should  be  put  on  a  fluid  diet,  and  have 
a  movement  of  the  bowels  every  day  for  at  least  a  week.  For  twelve 
hours  before  taking  ether,  the  stomach  should  be  kept  perfectly  free 
from  any  solid  food  or  milk.  About  two  ounces  of  whisky  in  an  equal 
quantity  of  water  should  be  taken  a  half -hour  before  the  anaesthesia  is 
commenced.  All  the  details  of  the  antiseptic  method  heretofore  given 
should  be  carefully  carried  out.  In  hospital  practice,  and  in  the  dusty 
season  of  the  year,  the  carbolic-acid  spray  should  be  kept  going  in 
the  operating-room  for  a  half-hour  prior  to  the  entrance  of  the  patient. 
The  pubes  and  abdominal  wall  thi'ough  which  the  incision  is  to  be  made 
should  be  shaved  and  disinfected,  and  the  bladder  emptied  before  the 
inhalation  is  begun,  unless  the  nervous  condition  of  the  patient  renders 
it  advisable  to  postpone  this  part  of  the  preparation  for  the  operation 
nntil  she  is  unconscious.  The  legs,  arms,  and  chest  should  be  carefully 
wrapped  in  warm  flannels  or  blankets.     The  patient  should  rest  upon 


LAPAROTOMY  FOR  THE  REMOVAL  OF  TUMORS.     777 

the  back,  with  the  legs  fully  extended,  or,  as  many  operators  prefer,  with 
the  sacrum  resting  near  the  end  of  the  table,  and  the  feet  in  a  chair, 
with  the  thighs  abducted  and  held  by  an  assistant  seated,  between  the 
feet,  in  the  chair.  The  incision  should  be  in  the  median  line,  about 
three  inches  in  length,  and  should  commence  about  five  inches  above 
the  OS  pubis.  The  recti  muscles  should  be  separated  and  all  bleeding 
arrested  by  catgut  ligatures  before  the  peritonaeum  is  opened.  When 
the  parietal  layer  of  the  peritonseum  is  reached,  catch  a  small  point  of 
this  membrane  with  a  tenaculum  or  forcejps,  grasp  this  point  between 
the  thumb  and  finger,  to  make  sure  that  no  omentum  or  intestine  is 
picked  uj),  and  make  a  small  incision  with  the  scissors.  Through  this 
opening  introduce  the  broad-grooved  director,  and  further  divide  the 
peritonaeum.  Two  fingers  should  now  be  carried  into  the  abdomen,  and 
a  careful  exploration  made.  A  blunt,  round  instrument  (a  No.  20  United 
States  urethral  sound  will  suffice)  carried  in  and  swept  over  the  tumor 
will  demonstrate  the  presence  of  any  adhesions  between  it  and  the  ante- 
rior wall  of  the  abdomen.  If  the  tumor  is  free,  drag  it  up  to  the  incis- 
ion ;  and,  if  it  is  cystic,  hold  it  so  that  with  the  aid  of  sponges  placed 
around  the  margins  of  the  incision  none  of  the  fluid  can  escape  into  the 
peritoneal  cavity.  Introduce  the  large  trocar  and  evacuate  the  fluid  con- 
tents. As  the  sac  is  being  emptied,  drag  it  farther  out  of  the  incision, 
and,  when  all  the  fluid  escapes,  free  the  tumor  of  all  adhesions  to  the 
intestines  or  other  structures.  All  large  adhesions  may  be  tied  with 
the  double  catgut  ligature,  and  cut  between,  while  small  adhesions,  or 
those  so  situated  that  the  ligature  is  impossible,  should  be  torn  through. 
Great  care  is  required  in  separating  the  sac  from  the  wall  of  the  intes- 
tine. As  soon  as  the  pedicle  is  freed,  the  sac  should  be  grasped  with  a 
long-jawed  pedicle  forceps  (Spencer  Wells's  sac-forceps)  and  cut  away. 
The  pedicle  should  be  transfixed  near  its  middle  with  an  aneurism-needle 
armed  with  a  large  double  silk  ligature  and  the  two  threads  drawn 
through.  In  tying  the  threads  on  either  side  of  the  pedicle  cross  them, 
as  shown  in  Fig.  666,  and  tie  firmly.  If  the  pedicle 
does  not  bleed,  the  ligatures  should  be  cut  short.  "'^"'"'1^""  --■-?= 
Ihe  ovary  01  the  opposite  side  should  be  examined.     ^     „„„    ^^    . 

mi  .  r      T       ^^      .  -,         -,  T     ,  ,.-,-,  Fi»-    666.— Showmpr  the 

ihe  cavity  ot  the  peritonaeum  should  be  carefully  manner  in  which  the 
washed  out  with  Thiersch's  solution,  with  the  aid  of  double i^gaVre should 
sponges  on  holders,  and  the  wound  closed  as  directed  tooTtheVecUc'ie.'^^"" 
in  laparotomy  for  intestinal  obstruction.  If  a  solid 
tumor  is  encountered,  and  when  a  cystic  tumor  has  such  thickened  walls 
that  it  can  not  be  readily  brought  out  at  the  wound,  the  incision  may 
be  enlarged.  It  is,  however,  advisable  to  keep  the  abdominal  wound  as 
small  as  possible  when  the  small  size  of  the  oi^ening  does  not  interfere 
with  the  safe  manipulation  within  the  abdomen.  Dermoid  cysts  are 
usually  so  solid  that  they  are  removed  without  an  effort  at  tapping. 

A  cyst  of  the  broad  ligament,  in  which  there  is  no  pedicle,  requires 
to  be  stripped  out  of  the  capsule,  the  capsule  stitched  to  the  margins  of 
the  abdominal  incision,  the  cyst-wall  beyond  the  line  of  sutures  cut 
away,  and  a  drainage-tube  inserted. 


778 


A  TEXT-BOOK   ON  SURGERY. 


The  tube  of  Dr.  H.  Marion-Sims  is  a  most  satisfactory  apparatus  for 
draining  the  pelvis  after  laparotomy  for  any  purpose  for  which  after- 
drainage  is  indicated  (Fig.  667). 

"It  consists  of  a  large  and  a  small  tube  made  of  hard  rubber. 
The  smaller  tube  is  inside  of  the  larger  one, 
running  along  the  posterior  wall  and  ter- 
minating about  an  eighth  of  an  inch  from 
the  bottom.  The  large  tube  is  perforated  on 
the  sides  and  curved  at  the  top,  so  that, 
when  in  the  abdominal  woiind,  the  top  of 
the  tube  projects  nearly  over  the  symphysis 
pubis.  To  this  a  rubber  tube  of  sufficient 
length  to  carry  the  fluid  used  in  washing- 
out  the  abdomen  into  a  convenient  vessel  is 
attached.  The  injection-fluid  is  forced  in 
by  a  Davidson's  syringe,  the  tube  of  which 
is  slipped  over  the  end  of  the  small  pipe  B  ; 
or  a  fountain  irrigator  may  be  preferred. 
As  the  wound  fills,  the  fluid  escapes  through 
the  larger  tube,  and  the  irrigation  should  be 
continued  until  the  water  comes  out  clear. 
By  the  siphon  action  of  this  apparatus  the 
discharge  from  the  greater  tube  will  be  con- 
tinued after  the  injection  is  stopped.  Just 
as  the  stream  is  about  to  stop,  the  tubes 
should  be  closed,  and  in  this  way  the  en- 
ti'ance  of  air  is  prevented.  The  lower  end, 
C,  of  this  tube  should  be  placed  in  the  most  dependent  portion  of  the 
cavity,  usually  in  Douglas's  cul-de-sac.'''' 

The  greatest  care  is  required  in  employing  drainage  in  the  peritoneal 
cavity,  especially  during  the  first  twenty-four  hours,  until  adhesions 
form,  which  practically  close  the  jDeritoneal  opening.  The  end  of  the 
drain  should  be  well  covered  with  sublimate  gauze,  and  during  the 
dressings  for  the  first  twenty-four  hours  it  would  be  advisable  to  use 
the  carbolic-acid  spray,  to  prevent  the  possibility  of  infection. 


Fio.  667.— Dr.  H.  Marion-Sims'i 
drainage-tube. 


CHAPTEE  XXI. 


DEFORMITIES. 


DEFORMITIES   OF  THE   SPINAL    COLUMN. 

A.WZ  noticeable  deviation  from  the  normal  curvatures  of  the  vertebral 
column  constitutes  a  deformity.  They  are  congenital  and  acquired,  tem- 
porary or  permanent.  They  are  divisible  into  tvs^o  great  classes,  namely, 
those  due  to  lesions  of  the  column  (bones  or  cartilages),  and  those  due 
to  lesions  of  the  soft  tissues  (muscles  and  ligaments).  To  the  former 
belong  dislocations,  fractures,  destructive  ostitis,  and  sijina  bifida  ;  to  the 
latter,  muscular  torticollis,  lateral  or  rotary -lateral  curvature  {scoliosis), 
stoop-shoulder  {cyphosis),  curvature  from  pleuritic  adhesions,  collapse 
of  the  lung,  contractions  of  cicatrices  following  burns,  scalds,  phleg- 
mon, etc. 

Lateral  and  Rotary-lateral  Curvature. — Simple  lateral  curvature  of 
the  spine — that  is,  a  bowing  to  one  side  without  rotation  of  the  vertebrae- 
is  extremely  rare.  It  may  occur  in  any  portion  of  the  column  to  a  slight 
extent,  although  rotation  is  very  apt  to  take  place  with  the  curvature. 
It  is  more  often  observed  in  the  cervical  region  than  elsewhere,  and  is 
known  as  torticollis,  or  ' '  lory-necJc. " 

The  causes  of  wry-neck  are — 1,  loss  of  parallelism,  or  balance  of 
power  between  opposing  muscles,   and    2, 
cicatricial  contractions. 

Muscular  torticollis  is  by  far  the  most 
frequent  foi'm,  and,  in  common  with  all  de- 
formities resulting  from  lesions  of  the  mus- 
cles, the  right  side  is  usually  affected.  The 
right  sterno-mastoideus  muscle  is  the  prin- 
cipal seat  of  tonic  spasm,  causing  this  or- 
gan to  stand  out  in  relief  ;  the  right  ear  is 
drawn  down  toward  the  clavicle  of  that  side, 
while  the  chin  points  well  to  the  left  (Fig. 
668).  The  trapezius  not  unfrequently  is  con- 
tracted with  the  mastoid  muscle.  The  sple- 
nius,  scaleni,  platysma  myoides,  or  levator- 
anguli  scapulse,  are  less  frequently  involved. 
Loss  of  equilibrium  between  the  muscles  of 

the  two  sides  occurs  chiefly  in  chlorotic  patients  in  which  the  normal 
muscular  tone  is  greatly  diminished,  rendering  the  organs  of  the  left  (or 


Fig.  6G8. — MuBCubi-  torticollis. 
(After  Sayre.) 


780 


A  TEXT-BOOK  ON  SURGERY. 


non-preferred)  side  unable  to  resist  the  more  developed  muscles  of  the 
right  half  of  the  body.  In  other  cases  the  lesion  may  be  situated  in  the 
central  nervoiis  ganglia,  or  in  the  track  of  the  nerve. 

Inhammation  of  the  muscular  substance  (myositis),  or  of  the  tendons 
or  sheaths  of  the  muscles,  is  an  occasional  cause  of  wry-neck.  Any  in- 
flammatory process  may  lead  to  shortening  of  the  muscles,  and  to  con- 
tractions in  the  fasciee  and  connective  tissues  of  the  neck.  Muscular 
torticollis  is  met  with  most  frequently  in  the  young,  may  exist  at  birth, 
is  seen  in  females  oftener  than  in  males,  and  in  this  class  of  cases  is  apt 
to  occur  about  the  age  of  ptiberty.  In  some  instances,  in  addition  to 
the  tonic  spasm  of  the  muscles  involved,  a  clonic  or  irregular  convulsive 
movement  occurs. 

Diagnosis. — The  recognition  of  torticollis  is  usually  free  from  difB- 
culty.  The  elimination  of  caries,  dislocation,  fracture,  and  wry-neck 
caused  by  cicatricial  contractions,  is  determined  from  the  history  of  the 
case  and  by  inspection  and  manipulation. 

When  one  sterno-mastoid  muscle  is  contracted,  the  chin  is  pointed  to 
the  opposite  side,  and  the  occiput  made  to  approximate  the  clavicle  of 
the  side  corresponding  to  the  contracted  muscle.  The  splenius  capitis 
draws  the  mastoid  process  downward  and  backward  toward  the  spine  of 
the  seventh  cervical  vertebra. 

The  prognosis  in  muscular  torticollis  is  usually  favorable — less  so  in 
.  '  clonic  than  in  tonic  muscular  spasm.    In 

wry-neck  due  to  contractions  of  the  fas- 
ciae, tendons,  etc.,  the  deformity  is  with 
difiicnlty  relieved. 

Treatment. — Chlorosis.,  or  any  dys- 
crasia,  should  be  treated  by  tonics  and 
internal  medication,  by  properly  select- 
ed diet  and  out-of-door  life.  The  devel- 
opment of  the  muscles  of  the  left  (or 
weaker)  side  is  essential.  Kneading, 
massage,  and  electricity  will  be  found 
useful  adjuvants.  Mechanical  appliances 
should  be  used  in  overcoming  the  con- 
tractions in  the  offending  muscles.  Arti- 
ficial muscles,  composed  of  elastic  bands 
or  rubber  tubing,  more  nearh'  fulfill  the 
indications.  The  origin  and  insertion 
should  correspond  to  that  of  the  normal 
muscle.  A  thoracic  belt  or  jacket  of 
plaster  of  Paris,  leather,  or  silicate  of 
soda,  properly  adjusted,  will  serve  for 
the  points  of  fixation  of  the  lower  end 
of  the  elastic  material.  The  upper  in- 
sertion near  the  occiput  is  best  secured 
by  a  stall  carried  around  the  head  above  the  ears  and  across  the  fore- 
head.    In  order  to  prevent  it  from  slipping,  the  portion  which  rests 


Fio,  669. — Eeynders's  apparatus  for  the  cor 
reotion  of  muscular  torticollis. 


MUSCULAE  TORTICOLLIS.  781 

upon  the  skin  of  the  forehead  should  be  made  of  strong  adhesive  plas- 
ter (as  advised  by  Prof.  Sayre),  The  tension  on  the  rubber  muscle  may 
be  increased  from  day  to  day,  if  necessary.  If  this  method  does  not 
succeed,  the  apparatus  of  Reynders  &  Co.  (Fig.  669)  sh(juld  be  tried. 
The  mechanism  is  vrell  shown  in  the  accompanying  cut,  the  correction 
of  the  deformity  being  effected  by  means  of  a  series  of  joints  situated 
at  the  back  of  the  neck,  which  are  worked  by  a  key,  and  can  be  fixed  at 
any  angle  of  flexion  and  rotation. 

The  operative  procedures  include  stretching  or  division  of  the  muscle 
or  muscles  affected,  tenotomy,  neurectomy,  division  of  the  fascia,  and 
the  free  dissection  of  cicatricial  tissue.  Of  these  operations,  tenotomy 
of  the  sterno-mastoideus  is  most  frequently  demanded.  A  puncture  is 
made  a  little  to  the  outer  side  of  the  clavicular  tendon  of  this  muscle, 
and  a  long,  probe-pointed  tenotome  slid  flatwise  (the  cutting-edge  down- 
ward) upon  the  outer  anterior  surface  of  the  clavicle.  As  soon  as  the 
point  of  the  instrument  has  passed  between  the  clavicular  and  sternal 
origins,  the  edge  is  turned  outward,  making  the  muscle  tense,  and  the 
tendon  is  divided  subcutaneously.  The  sternal  origin  is  divided  by  an 
additional  puncture.  After  tenotomy  the  prothetic  apparatus  should  be 
employed  until  recovery  is  complete.  In  dividing  the  body  of  this  mus- 
cle, or  the  trapezius,  splenius,  or  levator-anguli  scapulge,  the  open  method 
should  be  followed. 

Violent  and  sudden  stretching  of  the  muscles,  with  or  without  anjes-* 
thesia,  is  not  advisable.  Exsection  of  that  portion  of  the  spinal  acces- 
sory nerve  which  is  siipplied  to  the  sterno-mastoid  and  trapezius  mus- 
cles is  occasionally  performed  in  order  to  paralyze  the  permanently  con- 
tracted muscles.  It  is  preferable  to  a  simple  division  or  to  stretching 
of  the  nerve,  for  the  reason  that  a  divided  nerve  may  reunite,  and,  after 
stretching,  the  function  of  the  nerve  is  only  temporarily  impaired. 

In  order  to  expose  this  nerve,  make  an  incision  about  foxir  inches  in 
length,  following  the  posterior  border  of  the  sterno-mastoideus  muscle, 
and  commencing  on  a  level  with  a  point  half-way  between  the  lobule  of 
the  ear  and  the  angle  of  the  jaw.  The  fibers  of  the  muscle  should  be 
sought,  and,  recognizing  these,  the  posterior  edge  is  exposed.  By  keep- 
ing the  wound  diy,  and  working  close  to  the  under  surface  of  the 
muscle,  the  vessels  will  be  avoided  and  the  nerve  will  be  seen  running 
obliquely  downward  and  outward,  and  passing  into  the  muscle.  One 
or  two  superficial  nerves  are  sometimes  seen  radiating  from  the  cer- 
vical plexus.  From  one  half  to  one  inch  of  the  nerve  should  be  ex- 
cised. After  this  operation,  mechanical  treatment  should  be  instituted 
for  a  short  time. 

In  torticollis  due  to  cicatrices,  simple  division  of  the  conti-acting  tis- 
sue afllords  only  temporary  benefit.  The  only  legitimate  method  is  to 
dissect  out  the  offending  tissue,  slide  sound  skin  over  the  wound  thus 
made,  and  use  mechanical  treatment  until  the  deformity  is  overcome. 

Deformities  due  to  dislocations  and  fractures  of  the  cervical  verte- 
brae have  been  considered,  and  those  resulting  from  caries  of  this  portion 
of  the  spine  will  be  given  hereafter. 


782 


A  TEXT-BOOK   ON  SURGERY. 


Lateral  and  Rotary -lateral  Curmture  of  tlie  Dorsolumbar  Spine.— 
Simple  lateral  curvature  of  the  dorso-lumbar  spine  is  exceedingly  rare. 
It  is  complicated  in  almost  all  cases  by  rotation  of  the  vertebrae  upon 
each  other,  and  in  deformity  here  from  muscular  causes,  the  rotation 
precedes  the  lateral  curvature. 

Lateral  curvature  is  usually  caused  by  an  inequality  in  the  length  of 
the  lower  extremities.  Fig.  671  was  taken  from  a  boy  in  whom  the  right 
extremity  was  one  and  a  half  inch  shorter  than  the  left.  With  both 
soles  on  the  same  plane,  marked  lateral  curvature  (convexity  to  the  right) 
was  observed.  By  placing  the  foot  of  the  short  side  upon  a  book  of  the 
required  thickness,  the  deformity  disappeared  (Fig.  672). 


Fia.  670. — Lateral  curvature  after  reeov-  Fig.  671.  Fig.  C72. 

erj  from  lumbo-sacral  spondylitis. 

Inequality  in  the  length  of  the  lower  extremities  is  not  uncommon, 
even  in  individuals  who  have  not  suif ered  from  injury  or  disease.  A  dif- 
ference of  as  much  as  one  inch  has  been  noted,  while  from  one  half  to 
one  fourth  inch  is  quite  common. 

Cicatricial  contractions  on  one  side  of  the  chest  or  abdomen,  as  after 
extensive  burns  or  in  chronic  pleuritic  adhesions  with  collapse  of  the 
lung,  also  produce  this  deformity.  The  treatment  will  be  considered 
with  that  of  rotary-lateral  curvature. 

Rotary-lateral  Curvature. — Rotation  of  the  bodies  of  the  vertebrae 
upon  each  other,  and  upon  the  sacrum  and  subsequent  or  simultaneous 
lateral  curvature,  is  one  of  the  most  difficult  deformities  to  correct.  The 
chief  cause  is  loss  of  the  normal  equilibrium  of  the  muscles  of  the  two 
sides  of  the  trunk.     The  tendency  to  deformity  is  increased  by  the  habit 


ROTARY-LATERAL   CL'RYATURE. 


783 


of  sitting  sidemse  at  tlie  table  or   desk,  with   one  shoulder  drooping 
while  the  other  is  elevated.     A  large  majority  of  those  affected  are  chlo- 
rotic  girls,  between  thirteen  and  eighteen  years  of  age.     This  deformity 
is  occasionally  met  with  in  porters  or  laborers 
who  habitually  cany  heavy  weights  ui^on  one 
shoulder.     The  rotation  most  frequently  com- 
mences in  the  lumbar  region.     The  spines  twist 
to  the  right,  while  the  anterior  aspect  of  the 
bodies  of  the  vertebras  are  made  to  look  toward 
the  left.     The  convexity  of  the  curve  is  to  the 
left,  the  right  shoulder  is  prominent,  the  apex 
tilted  outward,  the  angles  of  the  ribs  on  this 
side  project  abnormally,  and  there  is  a  folding 
in  or  wrinkling  of  the  skin  between  the  iliac 
crest  and  the  thorax  (Fig.  673). 

The  chief  agent  in  this  distortion  is  believed 
to  be  the  latissimus-dorsi  muscle.  Acting  upon 
the  tips  of  the  long  spines  of  the  lumbar  verte- 
brae from  its  insertion  in  the  humerus  (and  indi- 
rectly through  the  pectoralis  major,  from  the 
clavicle  and  sternum),  the  spines  are  twisted  to 
the  right,  causing  the  rotation  of  the  bodies  to 
the  left ;  the  shoulder-blade  is  tilted  outward, 
and  the  ribs  are  bent  iinder  the  contraction  of 
this  long  and  comparatively  powerful  muscle. 

In  some  instances  the  abdominal  muscles  take 
part  in  the  unilateral  contraction,  while  in  oth- 
ers the  deformity  commences  with  the  rotation  of  the  dorsal  vertebrae  by 
the  action  of  the  serratus-magnus  and  rhomboidei  muscles.     Ko  matter 
where  the  primary  curve  takes  place,  a  second  or  comj)ensatory  curve 
follows  in  all  chronic  cases. 

The  diagnosis  of  rotary-lateral  cui-vature  will  depend  upon  the  promi- 
nence of  the  shoulder-blade,  bulging  of  the  ribs,  and  the  ajjproximation 
of  the  crest  of  the  ilium  and  thorax  of  the  right  (or  affected)  side.  Ca- 
ries of  the  spine  may  be  eliminated  by  the  absence  of  abnonnal  tempera- 
ture, freedom  from  pain  when  direct  pressure  is  made  from  the  head 
along  the  vertebral  column,  and  absence  of  symptoms  of  compression  of 
the  cord  or  nerves  in  the  intervertebral  notches.  Psoas  abscess  is  pres- 
ent in  a  certain  proportion  of  cases  of  ostitis  of  the  vertebrae. 

In  simple  lateral  curvature  the  ribs  are  not  projected,  as  when  rota- 
tion occurs,  nor  is  the  tip  of  the  shoulder-blade  so  prominent. 

The  prognosis  varies  with  the  character  of  the  lesion.  In  recent 
lateral  curvature,  due  to  inequality  of  length  in  the  extremities,  it  is 
favorable.  In  rotary-lateral  curvature,  within  the  &st  few  months  of 
the  lesion,  a  cure  may  be  effected.  In  old  cases,  while  the  deformity 
may  be  aiTested,  it  is' difficult  and  often  impossible  to  restore  the  nor- 
mal contour  of  the  spine  and  ribs. 

Treatment— WhsM  the  lesion  is  due  to  loss  of  equilibrium  in  the 


Fig.  673. — Eotaiy-lateral  curva- 
ture in  a  girl  fifteen  years 
of  age. 


784 


A  TEXT-BOOK  ON  SURGERY. 


Fio.  674. — Patient  lying  in  a  position  to  overcome  contraction  of  the 
muscles  of  the  left  side  of  the  abdomen  and  thorax.  (Alter 
Eeeves.) 


muscles  of  the  two  sides,  especial  attention  should  be  directed  to  the 
development  of  the  organs  of  the  weaker  side,  and  at  times  it  is  neces- 
sary to  impair  the  nutrition  of  the  muscles  of  the  stronger  half  of  the 

trunk.  When  the  de- 
formity is  on  the  right 
side,  the  muscles  of  the 
left  arm  and  side  should 
be  exercised  by  the  use 
of  the  dumb-bells,  elas- 
tic strap,  swing,  or  hori- 
zontal bar.  It  is  often 
advisable  to  place  the 
right  arm  and  hand  in 
a  sling,  to  prevent  the 
further  development  of 
these  muscles.  Mass- 
age or  kneading,  con- 
fined to  the  left  half  of 
the  body,  and  the  gal- 
vanic current  to  the  same  region  two  or  three  times  a  week  will  be  advis- 
able. Tonics,  judicious  feeding,  and  out-of-door  life  are  essential  feat- 
ures of  treatment.  The  patient  should  be  directed  to  sit  squarely  upon 
.  the  buttocks,  and  not 
to  droop  or  loll  to  one 
side.  In  reclining,  the 
body  should  be  placed 
in  such  a  position  that 
the  offending  muscles 
are  put  upon  the  stretch 
(Fig.  674).  The  de- 
formity is  temporarily 
overcome  by  the  em- 
ployment of  Wolff's 
cradle  (Fig.  675).  The 
belt  passes  over  the 
projecting  ribs  and 
shoulder  -  blade,     thus 

bringing  the  weight  of  the  trunk  upon  these  parts,  while  gravity  aids  in 
overcoming  the  curvature  in  the  lumbar  region. 

In  a  certain  proportion  of  cases,  mechanical  support  of  the  thorax  is 
indicated,  especially  in  those  cases  where  from  muscular  weakness  it  is 
almost  impossible  to  hold  the  spine  erect.  For  this  purpose  the  plaster- 
of-Paris  jacket  or  the  perforated  corset  may  be  used.  The  latter  (Figs. 
676,  677)  I  have  found  very  satisfactory.  It  is  to  be  commended,  for  the 
reason  that  it  can  be  readily  removed  at  night,  and  is  more  cleanly  than 
a  permanent  plaster  jacket.  When  the  gypsum  is  applied  it  should  be 
split  down  the  front,  taken  off  and  fixed  for  lacing  so  that  it  may  be 
removed  when  necessary. 


Fio.  675. — Wolff's  suspensory  cradle.  Patient  in  poBition  when  the 
contraction  is  on  the  riErht  side  (with  the  right  shoulder-blade 
and  ribs  projecting.     (After  Eeeves.) 


ROTARY-LATERAL   CURVATURE. 


785 


This  perforated  corset  is  made  as  follows :  A  plaster-of -Paris  jacket 
is  applied  as  hereafter  directed,  and  as  soon  as  this  hardens  (in  from  ten 
to  thirty  minutes)  it  is  split  down  the  median  line  in  front,  removed 
from  the  body,  and  the  cut  edges  placed  and  held  in  apposition  by  a 
bandage  carried  around  and  over  the  entire  jacket.  This  shell  is  to  be 
used  as  a  mold  in  which  a  cast  of  the  deformed  thorax  is  to  be  made. 
It  is  thoroughly  greased  on  its  inner  surface,  jilaced  ujDon  the  floor,  and 
filled  with  stifl'  j)laster-mortar.  When  this  hardens,  the  shell  is  removed, 
leaving  an  exact  cast  of  the  tho- 
rax, iipon  which  the  corset  is  to 
be  built. 

The  materials  needed  are  white 
glue,  ordinary  muslin  rollers,  flat 


Fig.  6T6.— Corset  made  after  Vance's  method. 


Fig.  6V7. — The  same,  applied. 


spring  steel  about  one  eighth  of  an  inch  wide  and  very  thin,  and  one 
yard  of  Canton  flannel.  Place  the  flannel  with  the  soft  plush  next 
to  the  plaster,  and  stitch  this  tightly  to  the  model,  so  that  it  is  not 
wrinkled.  It  should  be  sewed  only  along  the  middle  line  in  fi'ont.  The 
glue  should  now  be  dissolved  in  warm  water.  Strips  of  bandage  about 
two  feet  long  and  two  inches  in  width  are  dipped  in  the  glue  and  laid 
on  the  flannel  which  is  around  the  model.  As  soon  as  a  single  thick- 
ness has  been  applied,  strips  of  the  steel  wire,  cut  not  quite  as  long 
as  the  corset,  are  placed  one  inch  apart  over  its  entire  surface,  and 
held  in  place  by  a  string  wound  around  as  they  are  laid  on.  A  long, 
dry  roller  is  next  carried  around  the  model  from  above  downward, 
and  drawn  so  tight  that  the  steel  springs  are  made  to  conform  exactly 
to  the  surface  of  the  corset.  Upon  this  two  additional  layers  of  the 
short  strips  of  roller  dipped  in  glue  are  laid.  The  corset  should  be  left 
for  several  hours  in  the  hot  sun,  or  by  a  fire,  until  it  is  thoroughly 
dried.  It  is  then  split  down  the  front,  removed,  and  the  edges  bound 
with  chamois-skin.     Hooks  for  lacing  should  be  fastened  along  the  edges 

50 


786 


A  TEXT-BOOK   ON  SURGERY, 


in  front.  Perforations  may  be  made  between  tte  springs  with  a  wad- 
ding-punch. This  apparatus,  when  properly  made,  fits  accurately  about 
the  body  in  the  most  favorable  position  for  the  correction  of  the  deform- 
ity. It  can  be  removed  at  night  upon  retiring  and  for  bathing,  changes 
of  clothing,  massage,  and  electricity.  It  is  lighter  and  cleaner  than  the 
plaster-of- Paris  jacket.  When  the  necessary  materials  can  not  be  had, 
the  plaster  jacket  should  be  employed. 

Operative  interference  in  muscular  scoliosis  is  rarely  called  for.  In 
extreme  cases,  when  the  latissimus  dorsi  of  one  side  is  greatly  shortened 
and  increased  in  development,  correction  of  the  curvature  may  be  expe- 
dited by  the  subcutaneous  division  of  this  muscle. 

When  lateral  or  rotary -lateral  curvature  of  the  spine  results  from  in- 
equality in  the  length  of  the  lower  extremities,  the  first  indication  in 
treatment  is  to  elevate  the  shoe  of  the  short  side,  and  thus  bring  the 
plane  of  the  iliac  crests  at  a  right  angle  to  the  axis  of  the  vertebral 
column.  If  the  defornjity  is  not  entirely  corrected  by  this  plan,  the 
measures  just  detailed  should  be  also  employed. 

When  the  deformity  is  caused  by  superficial  cicatricial  contractions, 
their  division  is  essential.  In  pleuritic  adhesions,  with  collapse  of  the 
lung,  the  treatment  given  for  rotary-lateral  curvature  due  to  muscular 
asymmetry  should  be  adopted. 

Anterior  and  Posterior  Curvature  of  tTie  Spine. — Anterior  curvature, 
or  "stoop-shoulder,"  usually  occurs  in  the  dorso-cervical  regions;  occa- 
sionally the  entire  column  is  involved.  It  may  be  caused  by — 1,  partial 
or  complete  paralysis  of  the  erector  muscles  of  the  back  ;  2,  tonic  spasm 
of  the  abdominal  muscles  ;  3,  from  inadvertence,  as  in  the  habit  of  allow- 
ing the  shoulders  to  droop  forward,  with  or  without  the  carrying  of  bur- 
dens ;  4,  cicatricial  contractions  in  the  anterior  thoracic  and  abdominal 
regions ;  5,  heredity. 

Complete  paralysis  of  the  muscles  of  the  back  is  exceedingly  rare. 
Unilateral  paresis  is  not  altogether  uncommon.  The  most  freqiient 
condition  is  one  of  general  impairment  of  muscular  tone,  the  head  and 

upper  spine  gravitating  forward 
as  the  muscles  jaeld,  until  the 
posterior  ligaments  are  elongated 
and  the  anterior  margins  of  the 
intervertebral  disks  narrowed  by 
compression.  The  habit  of  car- 
rying a  heavy  burden  upon  one 
shoulder  is  more  likely  to  in- 
duce rotary-lateral  curvature  than 
cyphosis.  The  indications  are  to 
correct  the  deformity  by  the  use 
of  braces,  and  to  increase  the  tone 
of  the  muscles  the  nutrition  of  which  is  impaired. 

To  meet  the  former,  in  mild  cases  a  double  elastic  brace,  such  as  is 
shown  in  Fig.  678,  will  be  sufficient.  Massage,  electricity,  tonics,  and 
out-of  door  life  are  also  essential  features  of  treatment. 


Fig.  678. — Nyrop's  spring-brace.     (After  Eeeves.) 


SPONDYLITIS.  787 

Posterior  curvature  of  the  spine,  lordosis  or  "sway-back,"  is  far  less 
frequent  than  the  condition  just  described.  It  occurs  almost  always  in 
the  lumbar  region.  In  the  later  months  of  pregnancy  it  is  a  common 
condition,  and  is  met  with  in  individuals  with  unusual  development  of 
the  stomach  and  abdominal  viscera,  or  in  cases  of  chronic  abdominal 
tumor  (fibroid,  etc.). 

Spondylitis. — Destructive  ostitis  of  the  vertebrae,  commonly  known 
as  Pott's  disease,  occurs  usually  between  the  third  and  fifteenth  year  of 
life.  In  exceptional  instances  it  is  observed  prior  to  three  years  of  age, 
vAhile  not  more  than  one  fifth  of  all  cases  occur  after  the  fifteenth  year. 
It  is  therefore  eminently  a  disease  of  the  growing  period,  when  rapid 
nutritive  changes  are  taking  place  in  the  bones. 

WhUe  no  portion  of  the  spine  is  exempt,  the  disease  is  much  more 
frequent  in  the  dorsal  vertebrae,  which  are  involved  in  about  two  thirds 
of  all  cases.  The  lumbar  and  cervical  portions  of  the  column  are  about 
equally  liable  to  destructive  ostitis.  Occipito-cervical  disease  is  rare. 
Ostitis  in  the  lower  cervical  region  is  apt  to  involve  the  upper  dorsal  by 
extension,  and  the  same  is  true  of  ostitis  of  the  lower  dorsal  in  their 
relation  to  the  lumbar  vertebrae.  Lumbo-sacral  disease  is  not  altogether 
uncommon.  Destructive  ostitis  of  the  spine  is  divided  into  occipito- 
cervical, cervical,  cervico-dorsal,  dorsal,  dorso-litmbar,  lumbar,  and 
lumbo-sacral,  according  to  the  recognized  location  of  the  disease. 

Causes — Predisposing  and  Exciting.  — Any  disturbance  of  the  nor- 
mal process  of  nutrition  in  the  tissues  in  general — as  in  the  syphilitic, 
tubercular,  gouty,  or  rheumatic  dyscrasia — or  the  impairment  of  vitality 
resulting  from  any  acute  disease,  predisposes  to  inflammatory  changes  in 
the  bones,  and  especially  in  the  cancellous  tissue  of  the  vertebrae.* 
These  bones,  together  with  the  sternum  and  ribs,  are  the  last  to  take  on 
the  changes  which  occur  in  the  adult  bones — the  bones  of  completed 
growth  and  full  development.  In  the  pathology  of  ostitis  it  has  been 
pointed  out  that  the  medulla  of  these  bones  remains  in  its  red  or  embry- 
onic condition  long  after  that  in  the  other  bones  has  undergone  the  adult 
change,  and  that,  consequently,  they  are  for  a  prolonged  jieriod  liable 
to  accidents  consequent  upon  rapid  nutritive  changes,  and  especially  to 
capillary  rupture  and  extravasation,  f  How  much  more  liable  to  acci- 
dent and  disastrous  inflammation  are  these  structures  when  they  are 
weakened  in  the  general  impairment  of  nutrition?  The  chief  exciting 
cause  is  violence,  either  directly  or  indirectly  applied.  A  fall  upon  the 
feet,  buttocks,  or  hands,  or  violent  flexion  or  extension  of  the  vertebral 
column,  a  blow  upon  the  sterniim  or  ribs,  or  a  jienetrating  wound,  may 
each  lead  to  destructive  ostitis.  Carcinoma,  sarcoma,  and  aneurism  may 
also  cause  destruction  of  one  or  more  vertebrae.     It  is  believed  that  as 

*  "Les  tuberoules  des  os  s'sobserventhabituellement  dans  lestissu  spongieux  desos  longs  et 
dans  les  03  courts,  mais  leur  si6ge  de  predilection  est  le  corps  des  vertebres,  le  sternum  et  les 
cotes." — OORNIL  ET  Eanvier. 

t  "Les  OS  des  jeunes  sujets  et  oeus  qui  cbez  I'adulte  contiennent  encore  la  moelle  fcetale 
cornrae  le  sternum  et  les  corps  vert^braux  sont  particulidrement  espos6  aus  troubles  patho- 
logiques  nutritifs  ou  formateurs." — Ooenil  et  Kanvieb. 


788 


A  TEXT-BOOK   ON   SURGERY. 


between  the  predisposing  and  exciting  causes  of  Pott's  disease,  the  for- 
mer deserve  by  far  the  greater  consideration. 

Clinically,  destructive  ostitis  is  met  with  in  two  forms— the  dry  and 
the  suppurative.  The  latter  variety  is  more  common.  In  dry  ostitis  the 
bone-cells  imdergo  granular  metamorphosis,  and,  together  with  the  inor- 
ganic salts  of  this  tissue,  are  absorbed.  Suppuration,  if  present,  is  lim- 
ited, and  the  products  of  inflammation  undergo  fatty  degeneration.  In 
these  cases  the  breaking  down  of  the  bodies  of  the  vertebrae,  to  the  ex- 
tent of  marked  deformity,  may  occur  without  recognized  febrile  move- 
ment. In  the  supiDurative  form  the  destructive  process  is  more  rapid, 
and  is  accompanied  by  the  formation  of  a  variable  quantity  of  embryonic 
tissue,  the  bone  breaks  down  in  bulk,  and  particles  varying  in  size  ap- 
pear in  the  pus  which  results  from  the  inflammatory  process.  The  ear- 
liest pathological  change  in  such  cases  is  in  the  cancellous  tissue  of  the 
body.  In  rarer  instances  the  lesion  commences  as  a  synovitis  in  the 
costo-vertebral  or  interarticular  joints,  whence  the  disease  may  invade 
the  intervertebral  disks  and  bodies.  Primary  inflammation  of  the  inter- 
vertebral fibro-cartilage  is  believed  to  be  very  rare.  As  the  destructive 
process  continnes,  the  cancellous  tissue  of  the  body,  and  chiefly  of  the 
anterior  portions  of  the  column,  breaks  down  (Fig.  679),  causing  abnormal 


Fio.  679. — Destructive  ostitis 
of  tlie  anterior  portion  of 
the  bodies  of  ttie  vertebra. 
(After  Noble  Smith.) 


Fig.  680. — The  same  process 
in  the  posterior  portion  of 
the  bodies  of  the  vertebrie. 
(After  Noble  Smith.) 


Fig.  681. — Deformity  resulting 
from  fracture  of  a  vertebra. 
(Alter  Noble  Smith.) 


curvature,  with  sharp  projection  of  the  spinous  processes.  The  angular 
deformity  is  less  apt  to  be  present  when  the  disease  attacks  the  posterior 
portion  of  the  body,  where  the  superincumbent  weight  in  great  part  falls 
upon  the  articular  processes  (Fig.  680). 

Si/jnptoms.—The  clinical  history  of  Pott's  disease  may  be  divided 
into  two  stages  :  The  first  stage  includes  all  the  phenomena  which  occur 
up  to  the  time  when  deformity  is  recognized  ;  the  second  stage  embraces 
all  the  changes  met  with  after  deformity.  The  usual  symptoms  of  the 
first  stage  are  pain  and  muscular  rigidity,  with  varying  exacerbations  of 
temperature.  Pain  may  be  elicited  when  the  patient  assumes  the  erect 
posture,  by  direct  pressure  upon  the  spines  of  the  vertebrae  involved, 


SPOXDYLITIS.  789 

and  by  concussion  of  the  column  transmitted  from  the  head  downward. 
When  the  bodies  alone  are  involved  (the  usual  condition)  it  may  be  less- 
ened or  made  to  disapjDear  entirely  by  suspension  of  the  patient  from  a 
portion  of  the  column  above  the  lesion  ;  by  bending  the  spine  backward, 
thus  throwing  the  weight  upon  the  healthy  articular  processes ;  or  by 
laying  the  patient  face  downward  across  the  sui'geon's  lap,  and  making 
extension  by  separating  the  knees. 

Muscular  rigidity  is  i-ecognizable  in  a  majority  of  instances,  and  in 
childi-en  may  be  observed  as  a  symptom  of  pain,  when  the  presence  of 
pain  is  denied.  Fixation  of  the  dorsal  muscles  is  evident  in  the  stiff 
aud  unusual  manner  in  which  the  back  is  held  as  the  patient  moves 
about,  and  in  the  awkward  posture  assumed  while  sitting  down.  If 
directed  to  bend  the  vertebral  column,  as  in  stooping  to  pick  uj)  some- 
thing from  the  floor,  the  movements  are  cautious  and  constrained,  alto- 
gether lacking  in  the  celerity  and  suppleness  which  are  seen  in  flexion 
and  extension  of  the  vertebral  column  in  health.  In  the  earlier  stages 
pain  is  dull  and  steady  in  character,  and  is  usually  local,  being  confined 
to  the  neighborhood  of  the  part  affected. 

Elevation  oftemperaiure  maybe  present  at  any  stage  of  Pott's  disease. 
It  is,  as  a  rule,  the  index  of  the  extent  and  rapidity  of  the  inflammatory 
and  destructive  processes.  The  thennometer  may  register  from  the  nor- 
mal as  high  as  101°-102°  F.,  and  only  in  exceptional  instances  as  high  as 
104°.  In  a  fair  proportion  of  cases  in  the  early  stages,  and  especially  in 
the  dry  form  of  ostitis,  no  elevation  of  temperature  can  be  detected. 

The  second  stage  of  the  disease,  that  of  deformity,  may  be  laresent  in 
the  course  of  a  few  weeks  after  the  appearance  of  the  first  stage,  or  sev- 
eral months  may  elapse.  All  of  the  symptoms  of  the  preceding  stage  are 
present  in  the  second  stage  of  Pott's  disease.  If  proper  treatment  has 
not  been  instituted,  interference  with  the  functions  of  the  cord  at  and 
below  the  seat  of  lesion,  or  of  the  nerves  which  pass  out  between  the 
diseased  vertebrge,  is  apt  to  occur,  fi'om  displacement  of  the  bones  or 
as  a  result  of  inflammatory  products  pressing  upon  the  spinal  cord  and 
nerves.  Paralysis  of  motion  and  sensation,  in  a  varying  degree,  occurs 
in  a  certain  proportion  of  cases. 

When  deformity  occurs  the  convexity  of  the  curve  is  posterior  in 
about  95  per  cent  of  all  cases.  The  "  knuckle  "  may  consist  of  a  single 
spinous  process  (Fig.  328),  or  several  spines  may  project,  as  in  Fig.  670. 

The  degree  of  deformity  depends  upon  the  location  of  the  disease, 
its  extent,  and  in  part  to  general  relaxation  of  the  erector  muscles.  It  is 
greater  when  the  lower  cervical  and  upjjer  dorsal  vertebrse  are  involved 
(Fig.  681  a).  The  formation  of  pus  and  the  resulting  abscess  and 
sinuses  belong  chiefly  to  the  last  stage  of  ostitis  of  the  spine.  The 
abscess  may  travel  along  the  psoas  muscle,  opening  near  the  middle  of 
the  groin  above  or  beneath  Poupart's  ligament,  the  pus  may  escape 
through  the  inguinal  canal,  over  the  iliac  crest,  or  through  the  sacro- 
sciatic  notch  ;  or  it  may  be  arrested  at  a  higher  point  and  escape  recog- 
nition, unless  careful  examination  is  made  under  ether  narcosis. 

Spinal  abscess  is  usually  single,  occasionally  double.     When  occur- 


790 


A   TEXT-BOOK   ON   SURGERY. 


ring  in  the  upper  dorsal  region  it  may  be  arrested  by  the  diaphragm,  or 
pass  behind  this  into  the  sheath  or  fascia  of  the  psoas  muscle.  Abscess 
in  ostitis  of  the  bodies  almost  always  travels  downward  on  one  or  the 
other  side  of  the  antero-lateral  aspect  of  the  spine.  When  the  articular 
processes   or  laminse  are  involved,  the  pus   may  penetrate  the  dorsal 

muscles   and    point    poste- 
riorly. 

In  occipito- cervical  or 
upper  cervical  spondylitis, 
the  pus  collection  often  ap- 
pears at  the  posterior  wall 
of  the  pharynx  (^etropTiar- 
yngeal  abscess).  Interfer- 
ence with  deglutition  and 
phonation  is  not  infrequent. 
The  contents  of  an  abscess 
resulting  from  destructive 
ostitis  of  the  cervical  verte- 
brae may  also  descend  along 
the  deep  fascia  of  the  neck 
and  pass  into  the  thorax  or 
the  mediastinum.  In  this 
manner  it  occasionally  iinds 
its  way  into  the  pericardium. 
Amyloid  changes  of  the 
viscera  are  among  the  late 
symptoms  of  chronic  spon- 
dylitis. 

Diagnosis. — In  general 
the  recognition  of  the  dis- 
ease will  depend  upon  a 
history  in  accordance  with  most  of  the  symptoms  just  detailed.  As  to 
the  portion  of  the  column  involved,  the  axopreciation  of  localized  pain 
by  direct  or  indirect  pressure  is  an  indication  of  value.  When  the 
efferent  nerves  are  involved  by  pressure  from  the  products  of  inflamma- 
tion, certain  disturbances  in  their  course  or  distribution  are  of  diagnostic 
importance.  Spasm  of  the  larynx,  pharynx,  diaphragm,  pain  down  the 
arm,  etc.,  naturally  attract  attention  to  the  points  of  exit  of  the  nerves 
supplying  these  parts.  When  tenderness  in  the  region  of  the  psoas  mus- 
cles is  evidenced  by  habitual  indisposition  to  extend  the  thighs,  lumbar 
ostitis  may  be  suspected.  When  the  gibbosity  is  recognized,  a  diagnosis 
is  no  longer  doubtful.  The  early  recognition  of  abscess  in  the  abdominal 
region  is  possible  only  by  palpation  under  profound  narcosis. 

If  the  articular  processes  are  diseased,  bending  of  the  spinal  column 
backward  will  increase  the  pain.  Placing  the  patient  on  the  abdomen, 
with  the  head  and  lower  extremities  depressed,  will  diminish  it.  When 
the  bodies  and  intervertebral  disks  are  involved,  bending  the  spine  back- 
ward will  relieve  the  pressure  symptoms. 


Fig.  681  a.— Caries  of  the  bodies  of  the  third,  fourth,  and  ■ 
fifth  cervical  vertcbrffi. 


SPONDYLITIS. 


791 


Treatment.— In  the  mechanical  treatment  the  indications  are  to  se- 
cnre  fixation  of  the  spinal  column  in  the  position  of  least  discomfort  to 
the  patient.  Judicious  medication,  good  food,  and  pure  air  are  the  indi- 
cations in  the  constitutional  treatment.  The  character  of  the  mechanism 
to  be  used  will  depend  in  good  part  upon  the  portion  of  the  vertebral 
column  involved.  It  is  essential,  in  order  that  any  apparatus  may  fully 
meet  the  indications,  that  not  only  shall  the  diseased  bones  and  the 
healthy  tissues  be  held  practically  immovable,  but  the  superincumbent 
weight  must  in  whole  or  jjart  be  lifted.  Fixation  may  be  accomplished 
by  any  form  of  well-adjusted  apparatus,  but  lifting  the  weight  of  the 
body,  which  is  above  the  seat  of  disease,  is  a  more  difficult  undertaking. 

The  downward  pressure  upon  the  bodies  when,  as  is  usual,  these 
structures  are  involved  and  breaking  down,  can  be  in  great  jmrt  obviated 
by  extension  or  backward  bending  of  the  spine,  in  which  manoeuvre  the 
pressure  is  transferred  from  the  bodies  and  intervertebral  disks  to  the 
articular  processes  and  pedicles. 

Much  of  the  appai-atus  devised  for  the  arrest  and  cure  of  Pott's  disease 
Is  based  upon  this  principle.  Another  method  is  based  upon  the  principle 
of  lifting  the  parts  above  the  seat  of  the  lesion,  and  removing  the  press- 
ure in  a  greater  or  lesser  degree,  not  only  from  the  bodies  but  also  from 
the  articular  processes  (extension  and  counter-extension,  or  suspension). 

To  accomplish  the  former  the  spinal  braces  of  Drs.  Davis,  Taylor, 
and  Shaffer  have  been  constructed.  For  complete  extension  or  lifting,  the 
plaster-of-Paris  jacket  or  the  jury-mast  of  Prof.  Sayre,  and  the  suspen- 
sion-carriage of  Dr.  Meigs  Case,  more  nearly  meet  all  the  indications. 

In  appropriate  cases  each  of  these  forms  of  apparatus,  if  properly 
adjusted  and  intelligently  worn,  will  accomi^lish  all  that  is  possible  in 
the  mechanical  treatment  of  Pott's  disease.  Much  of  the  discredit  which 
is  brought  uj^on  particular  appa- 
ratus can  justly  be  charged  to  the 
lack  of  judgment  in  the  selection 
of  cases,  want  of  skill  in  the  ad- 
justment of  the  instrument,  and 
failure  on  the  part  of  the  attend- 
ant or  patient  in  persisting  in  its 
use  a  sufficient  length  of  time. 

The  selection  of  the  ai:)paratus 
best  adapted  to  succeed  •rtJI  de- 
pend upon  the  location  of  the  dis- 
ease and  the  age  and  conformation 
of  the  patient.  Clinically  the  spi- 
nal column  is  divisible  into  three 
regions :  1,  embracing  the  occipito- 
cervical articulation,  the  cervical 
vertebrae,  and  down  to  the  third 
dorsal ;  2,  from  the  third  to  the 
tenth  dorsal :  3,  from  the  tenth  dor-  ^         .  ^     „        ,  ■       , 

'      '  Fig.  682.— Suspension  apparatus  for  applvmg  plas- 

Sal  to  the  SacrO-lumbar  articulation.  ter-ot-Parls  jacket.     (After  Sayre.) 


792 


A  TEXT-BOOK   ON  SURGERY. 


Tlie  lower  region  is  more  amenable  to  treatment,  the  uj^per  next, 
while  the  middle  region,  which  is  most  frequently  involved  in  ostitis,  is 
the  most  difficult  to  manage. 

Tliird  Region. — In  the  mechanical  treatment  of  Pott's  disease  in  the 
third  region,  Sayre's  plaster-of -Paris  jacket,  of  light  make  and  prop- 
erly adjusted,  is  preferable.  In  its  application  the  following  articles 
are  essential : 

1,  A  suspension  apparatus  ;  2,  a  tight-fitting,  seamless,  knit  shirt ;  3, 
plaster-of-Paris  bandages.     The  suspension  apparatus  of  Reynders  &  Co. 

(Fig.  682)  gives  perfect 
satisfaction.  It  consists 
of  an  ii'on  cross-bar  from 
which  are  suspended  pad- 
ded loops  for  each  axilla, 
and  a  chin  and  occiput 
swing  for  lifting  from  these 
points.  The  cross-bar  is 
attached  at  its  center  to  a 
block  and  pulley.  After 
the  knit  shirt  is  applied, 
the  arms  of  the  patient  are 
slipped  through  the  pad- 
ded loops,  while  the  collar 
is  buckled  around  beneath 
the  chin  and  occiput.  The 
center  and  lateral  suspen- 
sion-straps should  be  ad- 
justed so  that  when  the 
lift  is  made  the  tension 
will  be  equally  distributed. 
The  block  of  the  pulley 
apjDaratus  may  be  fastened 
to  a  hook  in  the  ceiling 
or  to  the  tripod  (Fig. 
683).  The  plaster  band- 
ages— the  method  of  pre- 
paring which  is  given  on 
page  11 — should  be  per- 
fectly fresh  and  well  made, 
for  a  good  deal  of  success 
depends  upon  the  quality  of  the  gypsum  and  the  thoroughness  with 
which  it  is  worked  into  the  meshes  of  the  crinoline.  As  the  direction 
for  applying  this  jacket,  as  given  by  Prof.  Sayre — to  whom  the  profes- 
sion is  indebted  for  bringing  it  so  prominently  into  use — can  not  be 
improved  upon,  I  give  it  in  his  language  : 

"  Before  applying  the  plaster  bandage,  I  place  over  the  abdomen,  be- 
tween the  shirt  and  the  skin,  a  pad  composed  of  a  towel  folded  up  so  as 
to  form  a  wedge-shaped  mass,  the  thin  edge  being  directed  downward. 


'.^Suspension  apparatus  and  tripod  in  position  tor  lifting. 
(After  Sayre.) 


SPONDYLITIS.  793 

This  is  intended  to  leave  room,  when  removed,  for  the  expansion  of  the 
abdomen  after  meals,  and  so  I  call  it  the  '  dinner-pad.'  It  is  imj)ortant 
to  make  it  thin  where  it  comes  nnder  the  lower  edge  of  the  jacket,  or  else 
the  jacket  would  fit  too  loosely  about  the  lower  part  of  the  abdomen.  It 
should  be  taken  out  just  before  the  plaster  sets.  It  is  always  a  good  plan 
to  get  the  patient  to  eat  a  hearty  meal  before  the  jacket  is  apj)lied,  but 
this  precaution  of  allowing  room  for  meals  should  never  be  neglected. 

"  If  there  are  any  very  prominent  spinous  processes  which,  at  the  same 
time,  may  have  become  inflamed  in  consequence  of  pressure  produced  by 
instruments  previously  worn,  or  from  lying  in  bed,  siich  places  should  be 
guarded  by  little  pads  of  cotton  or  cloth,  or  little  glove-fingers  filled  with 
wool  placed  on  either  side  of  them.  Another  detail,  which  I  have  found 
to  be  of  practical  value  in  some  cases,  is  the  application  under  the  shirt, 
over  each  anterior  iliac  spine,  of  two  or  three  thicknesses  of  folded  cloth 
three  or  foiir  inches  in  length.  If  these  little  pads  be  removed  just  be- 
fore the  plaster  has  completely  set,  such  bony  processes  will  be  left  free 
from  pressure. 

"  If  the  patient  be  a  female,  and  especially  if  she  be  developing  at  the 
time,  it  will  be  necessary  to  apj^ly  a  pad  under  the  shirt  over  eacli  breast 
before  the  plaster  bandage  is  put  on.  These  joads  should  be  removed  just 
before  the  plaster  sets,  and  at  the  same  time  slight  pressure  should  be 
made  over  the  sternum  for  the  purpose  of  indenting  the  central  portion 
of  the  plaster  jacket,  and  of  thus  giving  form  to  the  body,  and  of  remov- 
ing pressure  from  the  breasts. 

"The  skin-fitting  shirt  having  been  tied  over  the  shoulders,  and  then 
pulled  down,  and  kept  stretched  by  means  of  tapes  applied,  one  in  front, 
the  other  behind,  near  its  lower  edge,  and  tied  tightly  over  a  handker- 
chief placed  on  the  perineeum,  the  patient  is  to  be  gently  and  slowly 
drawn  up  by  means  of  the  apparatus  until  he  feels  perfectly  comfortable, 
and  never  beyond  that  point,  and  while  he  is  retained  in  this  position  the 
plaster  bandage  is  to  be  applied.  A  prepared  and  saturated  roller,  which 
has  been  gently  squeezed  to  remove  all  surplus  water,  is  now  applied 
around  the  smallest  part  of  the  body,  and  is  carried  around  and  around 
the  trunk  downward  to  the  crest  of  the  ilium,  and  a  little  beyond  it,  and 
afterward  from  below  upward  in  a  spiral  dii'ection,  until  the  entire  trunk 
from  the  pelvis  to  the  axillse  has  been  incased.  The  bandage  should  be 
placed  smoothly  around  the  body,  not  drawn  too  tight,  and  especial  care 
taken  not  to  have  any  single  turn  of  the  bandage  tighter  than  the  rest. 
Each  layer  of  bandage  should  be  rubbed  most  thoroughly  with  the  hand 
by  an  assistant,  that  the  plaster  may  be  closely  incorporated  in  the  meshes 
of  the  crinoline,  and  bind  together  the  various  bandages  which  make  up 
the  jacket,  thus  making  it  much  stronger  than  if  attention  is  not  paid  to 
this  particular.  If  you  notice  any  spot  which  seems  weak  or  likely  to 
give  way,  pass  the  bandage  over  it,  and  then  fold  it  back  on  itself,  and 
do  this  until  you  have  placed  several  thicknesses  of  bandage  over  this 
point,  being  careful  to  wet  all  well  together,  and  then  pass  a  turn  com- 
pletely around  the  trunk  to  retain  any  ends  which  might  have  a  tendency 
to  become  detached. 


794  A  TEXT-BOOK   ON  SURGERY. 

"  In  a  very  short  time  the  plaster  sets  with  sufficient  firmness,  so  that 
the  patient  can  be  removed  from  the  suspending  apparatus,  and  laid 
upon  his  face  or  back  on  a  hair  mattress,  or— what  is  preferable,  espe- 
cially when  there  is  much  projection  of  the  spinous  processes  or  sternum 
—an  air-bed.  Before  the  plaster  has  completely  set,  the  dinner-pad  is  to 
be  removed,  and  the  plaster  gently  pressed  in  with  the  hand  in  front  of 
each  iliac  spinous  process,  for  the  purpose  of  widening  tbe  jacket  over 
the  bony  projections.  In  the  case  of  a  young  child  with  a  small  pelvis 
it  may  happen  that  the  circumference  of  the  body  at  the  umbilicus  is  as 
great  as  around  the  pelvis,  but,  as  the  soft  parts  in  the  lumbar  region 
allow  us  to  mold  the  plaster  as  we  choose,  you  can  still  obtain  a  point  of 
support  at  the  pelvis ;  if,  as  the  jacket  hardens,  you  will  press  it  in  at 
the  sides  above  the  ilium,  and  in  front  and  rear  above  the  pubes,  the  an- 
tero-posterior  diameter  above  will  be  the  longer,  while  below  it  will  be 
the  transverse  one." 

When  the  angular  projection  is  extreme,  or  when  an  ulcer  exists,  it 
will  be  advisable  to  cut  a  hole  in  the  jacket  at  this  point,  large  enough  to 
prevent  any  undue  pressure.  In  case  of  abscess,  a  window  of  sufficient 
size  to  allow  free  drainage,  and  a  frequent  change  of  dressing,  should  be 
made. 

The  commendable  features  of  this  plan  of  treatment  are  the  extension 
obtained  by  suspension,  fixation  by  the  plaster  while  in  the  most  favor- 
able position,  and  the  cheapness  and  readiness  with  which  it  may  be  em- 
ployed. 

The  objections  are,  uncleanliness  by  reason  of  the  immovable  nature 
of  the  apparatus,  and  the  excoriations  which  are  a  cause  of  considerable 
complaint.  The  first  objection  may  be  met  by  splitting  the  corset  down 
in  front,  and  reapplying  it  while  the  patient  is  suspended,  and  making  it 
tight  by  a  roller  carried  around  the  body  several  times.  As  for  excoria- 
tions, it  may  be  said  that  no  apparatus  which  grasps  the  body  tight 
enough  to  secure  fixation  is  free  from  this  danger.  When  they  occur 
wdth  the  plaster  jacket,  the  fault  generally  lies  either  in  the  improper 
manner  of  its  application  or  carelessness  on  the  part  of  the  attendant. 

Second  Region. — When  the  middle  or  dorsal  region  is  involved,  the 
plaster  jacket  is  not  so  serviceable  as  in  ostitis  of  the  vertebrae  in  the 
lower  region  of  the  spine,  although  much  good  will  be  accomj^lished  by 
the  partial  fixation  of  the  thorax  as  high  as  to  the  level  of  the  axillae. 
The  efficacy  of  this  method  diminishes  the  higher  the  diseased  process 
is  located,  and,  when  the  lesion  invades  the  sixth  dorsal,  or  above  this 
point,  the  jacket  without  head-suspension  is  almost  useless.  In  all  cases 
of  Pott's  disease  above  the  tenth  dorsal,  suspension  of  the  head  is  an 
essential  feature  of  treatment.  A  favorable  result  would  be  achieved  in 
a  greater  proportion  of  cases  if  this  point  were  insisted  upon,  and  the 
prejudice  against  the  suspension  apparatus  overcome. 

In  its  application  the  patient  should  be  suspended  as  just  described, 
and  a  plaster  jacket  applied  from  just  above  the  trochanters  up  as  high 
as  the  axillae.  After  two  layers  of  the  plaster  bandages  have  been  ap- 
plied, the  jury-mast  is  adjusted,  and  its  framework  covered  in  with  the 


SPONDYLITIS. 


795 


succeeding  layers  of  bandage.  The  jury-mast  (Pig.  684)  consists  of  a 
back-piece,  in  shape  not  unlike  the  inverted  letter  U,  made  of  soft  iron, 
which  enables  it  to  be  accurately  molded  to  fit  the  surface  to  which  it  is 
applied.  To  this  are  fastened  two  or  three  strips  of  tin,  made  rough  by 
a  series  of  perforations  with  an  awl.  To  the  upper  end  of  the  back-piece 
a  curved  bar  of  light  steel  is  attached,  in  such  a  manner  that  it  can  be 
raised  or  depressed  at  will.  At  the  end  of  this  crane  is  a  light  cross-bar, 
hooked  at  each  exti'emity,  from  which  the  collar  is  suspended.  After 
the  first  two  layers  of  plaster  bandages  have  hardened,  the  apparatus  is 
bent  to  fit  the  surface  of  the  back,  and  is  adjusted  to  the  jacket,  with 
the  middle-piece  or  crane  exactly  in  the  median  line  of  the  back  of 
the  neck  and  occiput,  and  its  extremity  over  the  center  of  the  top  of 
the  head,  so  that  traction  by  the  strips  will  be  directly  upward.     It  is 


Fi8.  684. — Sayre's  jury-mast  head- swing. 
(After  Say  re.) 


Fig.  685. — Jury-mast  apparatus  applied. 
(After  Sayre.) 


fastened  by  carrying  plaster  rollers  over  the  tin  strips  and  back-piece, 
and  working  in  plaster- mortar.  When  the  plaster  hardens  the  apparatus 
is  immovably  incorporated  into  the  jacket.  The  suspension-collar  shoiild 
now  be  buckled  beneath  the  occipital  protuberance,  and  the  strips  tight- 
ened enough  to  lift  the  weight  of  the  head  from  the  neck.  The  jacket 
may  be  converted  into  a  movable  corset,  by  splitting  it  along  the  middle 
line  in  front  and  attaching  hooks  for  lacing  (Fig.  685).  If  the  jury-mast 
can  not  be  applied,  in  ostitis  involving  the  vertebrae  between  the  third 
and  ninth  dorsal,  Shaffer's  modification  of  Taylor's  brace  should  be  pre- 
ferred. 

"  It  consists  (Fig.  686)  of  the  pelvic  band,  A,  to  which  are  riveted  two 
perfectly  plain  uprights,  B  B,  of  annealed  bar-steel,  which  uprights  ex- 
tend to  the  shoulder-pieces,  B  B,  and  are  steadied  at  a  point  opposite 


796 


A  TEXT-BOOK  ON   SURGERY. 


the  scapulse  by  the  cross-pieces,  E  E.  The  pads  at  C  C  are  simple  rolls 
of  Canton  flannel  stitched  to  the  uprights  by  transverse  threads,  shown 
in  the  engraving.  P  represents  the  location  of  the  deformity,  and 
F  F  F  F  shows  the  plaster  zone  securing  the  uprights  in  firm  contact 
with  the  tissues  lying  over  the  transverse  processes. 

"  Fig.  687  illustrates  the  anterior  apj)earance  of  the  apparatus.  F  F 
are  the  shoulder-straps,  passing  from  the  ends  of  the  shoulder-pieces, 
D  D  (Fig.  686),  to  the  buckles,  HH  (Fig.  686).  J  is  a  piece  of  padded 
webbing  crossing  the  anterior  and  superior  wall  of  the  thorax.  It  is 
secured  2X  G  G  (Fig.  686).     L  is  also  a  piece  of  padded  webbing,  which 


^    \ 


Fig.  686.— Shaffer's  apparatus. 
(After  Shaffer.) 


7. — Front  view  of  Shaffer's  apparatus. 
(After  Shaffer.) 


completes  the  circumference  of  the  pelvis  by  fastening  at  the  buckles 
attached  to  the  pelvic  band  A  (Fig.  686).  ^represents  the  anterior  ap- 
pearance of  the  plaster  zone. 

"  At  i)  D  (Fig.  686)  and  at  ^.S"  (Fig.  687)  are  the  shoulder-pieces,  which 
prevent  pressure  and  serve  as  points  of  attachment  for  the  axillary  straps, 
so  that  these  axillary  straps,  in  passing  over  the  shoulders,  shall  not 
exert  undue  downward  pressure.  Being  annealed,  these  shoulder-pieces 
may  be  bent  in  any  direction  desired  ;  and  they  should  be  curved  so  that 
a  very  little  space  exists  between  them  and  the  subjacent  parts.     The 


SPOXDYLITIS. 


^97 


pelvic  base  forms  a  sufficient  support  for  the  apparatus,  and  it  becomes 
quite  frequently  necessary  to  apply  perineal  pads  to  prevent  the  moving 
upward  of  the  apparatus,  rather  than  to  adjust  shoulder-pieces  to  keep 
the  appliance  from  slipping  down. 

"To  prepare  and  adjust  the  apparatus:  1.  Take  two  light  bars  of 
annealed  steel,  of  a  length  which  corresponds  to  the  distance  between  the 
commencement  of  the  anal  commissure  and  the  spinous  process  of  the 
second  dorsal  vertebrse.  These  form  the  uprights.  2.  A  piece  of  sheet- 
steel,  about  one  inch  wide  and  long  enough  to  reach  from  the  top  of  one 
trochanter  major  to  the  other  ;  bend  it  to  correspond  with  the  transverse 
sacro-iliac  region,  and  cover  with  chamois  or  other  soft  material.  This 
forms  the  hip-band.  3.  Two  cross-pieces,  four  or  five  inches  long,  which 
are  riveted  to  the  uprights  at  points  which  correspond  to  the  lower  border 
of  the  axilla  and  the  inferior  angle  of  the  scapula.  4.  Two  small  pieces 
of  light  bar-steel,  about  two  and  a  half  inches  long,  which  are  covered 
and  riveted  to  the  upper  end  of  the  uprights,  at  an  angle  of  about  45°, 
and  bent  as  shown  in  the  engTaving.  Buckles  are  now  attached  to  the 
ends  of  the  shoulder-pieces,  the  cross-pieces,  and  the  pelvic  band.  The 
distance  between  the  uprights  should  be  about  one  inch  and  a  quarter,  or 
sufficient  to  avoid  any  pressure  upon  the  spinous  processes.  These  com- 
ponent parts  being  riveted  together,  two  rolls  of  Canton  flannel,  about 
three  eighths  of  an  inch  thick,  and  a  little  wider  than  the  upright  bar, 
are  now  prepared.  They  should  reach  from  about  one  inch  above  the 
pelvic  band  to  the  lower  cross-piece.  Two  broad  webbing-bands,  as  shown 
at  /  and  L  (Fig.  687),  are  then  made  ready.* 

"  The  patient  is  j)laced  upon  two  tables  of  equal  height,  and  the  tables 
are  then  separated  so  that  the  jjarts  selected  for  the  zone  may  be  freely 
accessible  from  all  sides.  One  assistant  grasps  the  patient  under  the 
axillge,  the  other  makes  steady  but  easy  traction  at  the  thighs.  While  the 
patient  is  in  this  prone  position,  the  operator  iits  the  uprights  to  the  Line 
of  the  transverse  processes  ;  in  other  words,  adjusts  the  ajDparatus  to  the 
defoiinity.  A  pair  of  '  monkey-wrenches'  may  be  easily  used  as  a  paii* 
of  levers  with  which  to  bend  the  annealed  steel  uprights  into  amy  position. 
It  takes  but  a  few  moments  to  adapt  the  uprights  to  the  deformity.  In 
the  mean  time  the  patient  is  quiet.  He  does  not  struggle  nor  cry.  The 
traction  is  affording  relief,  and  is  not  producing  any  injury.  "While  he 
lies  quietly,  and  the  Canton  flannel  pads  are  sewed  on,  we  pass  a  piece  of 
Canton  flannel,  or  merino  gauze,  around  the  body  over  the  projection. 
Then,  the  plaster  bandages  and  everything  being  in  readiness,  the  appa- 
ratus is  laid  on  the  back  accurately,  traction  is  steadily  maintained,  the 
thoracic  and  pelvic  sti-aps  are  fastened,  and  the  plaster  zone  is  snugly 
applied.     The  axillary  straps  are  left  until  the  plaster  is  hardened,  and 

'  "  Messrs.  Tiemann  &  Co.,  Xo.  6T  Chatham  Street,  New  York,  will  fnrnish  this  apparatus 
at  a  cost  of  from  five  to  seven  dollars,  according  to  size.  It  would  also  be  well,  in  sending  the 
measurements,  to  inclose  an  outline  of  the  spinal  column,  from  the  spinous  process  of  the  second 
dorsal  down.  This  may  be  done  by  placing  a  strip  of  lead  along  the  spinous  processes,  and 
molding  it  accurately  to  the  outline  presented.  By  transferring  this  lead  carefully  to  a  sheet  of 
paper,  an  accurate  profile  of  the  spine  may  be  obtained  with  a  lead-pencil  tracing. 


798 


A   TEXT-BOOK   ON   SURGERY. 


the  patient  is  ready  to  sit  up. 
When  the  operation  is  complete, 
the  patient  is  firmly  secured  in 
an  apparatus  which  afl'ords  a  sup- 
port that  can  be  maintained  by 
the  thoracic,  axillary,  and  pelvic 
straps,  and  the  uprights  are  held, 
without  undue  pressure,  in  their 
position  by  the  plaster  zone."* 

The  value   of   this  apparatus 
consists  in  the  fair  degree  of  fixa- 
tion which  it  secures,  but  chiefly  in 
the  dorsal  spine  is  extended,  that 


Fig.  689. — Dr.  Meigs  Case'.s  suspension-carriage, 
standing  and  sitting  postiu'es. 


Fig.  688. — Extension  in  the  recumbent  posture. 
(After  Eeeves.) 

the  fact  that,  when  properly  applied, 
is,  bent  backward  to  such  a  degree 
that  the  weight  from 
above  is  removed  from 
the  diseased  bodies  and 
transferred  to  the  sound 
articular  processes  and 
pedicles.  If  this  posi- 
tion is  properly  main- 
tained, relief  will  usual- 
ly follow  in  those  cases 
where  the  bodies  alone 
are  involved.  Instead 
of  the  plaster  zone,  a 
broad  canvas  or  soft 
leather  belt  may  be  used. 
First  Region.  —  In 
ostitis  of  the  vertebral 
column,  from  the  third 
dorsal  to  the  occipito- 
atloid  articulation,  the 
treatment  should  be  by 
suspension  from  the  chin 
and  occiput.  In  accom- 
plishing this  end  the 
jury-mast,  applied  and 
worn  as  just  described, 
is  entitled  to  the  first  con- 
sideration. Much  good 
may  be  obtained  from 
the  judicious  use  of  ex- 
tension in  the  recumbent 
posture  (Fig.  688).  This 
apparatus  may  be  worn 
at  night,  when  the  head 


'  Pott's  Disease,"  etc.,  N.  M.  Shaffer,  M.  D.     G.  P.  Putnam's  Sons,  New  York,  1879. 


SPINA  BIFIDA. 


799 


stall  of  jury-mast  is  removed.  In  the  worst  class  of  cases  it  is  advisable 
to  employ  the  extension  in  bed  until  the  symptoms  of  paralysis  are 
relieved.  Instead  of  the  block  and  pulley,  with  weight,  the  extension 
may  be  made  by  elastic  bands  attached  to  the  chin-and- occiput  collar 
a,nd  the  head  of  the  bed,  while,  if  necessary,  fixation  may  be  secured 
by  elevating  the  head  of  the  bed  six  or  eight  inches. 

The  suspension-carriage  of  Dr.  Meigs  Case,  which  lifts  from  the  axillee, 
chin,  and  occiput  (Fig.  689),  is  a  valuable  apparatus  in  the  treatment  of 
Pott's  disease  in  the  cervical  and  upper  dorsal  region.  If  the  degree  of 
elastic  suspension  from  the  chin  and  occiput  which  it  affords  during  the 
waking  hours  is  continued  during  sleep,  by  the  method  of  extension  in 
the  recumbent  posture  above  given,  success  would  be  achieved  in  the 
majority  of  cases.  It  is  chiefly  objectionable  by  reason  of  its  high 
price,  which  places  it  beyond  the  reach  of  many  who  can  obtain  the 
jury-mast. 

The  successful  management  of  Pott's  disease  depends  not  only  upon  a 
thorough  practical  knowledge  of  the  construction  and  application  of  the 
mechanical  apparatus  required,  but  upon  the  careful  and  constant  atten- 
tion of  a  competent  surgeon  during  the  entire  time,  from  the  incij^iency 
of  the  spondylitis  until  several  months  have  elapsed  after  consolidation 
is  effected.  The  prevention  of  chafing  and  sores,  the  opening  and  drain- 
age of  abscesses,  the  renewal  or  tightening  of  the  apparatus,  require  just 
as  much  skill  as  in  the  diagnosis  and  first  adjustment  of  the  mechanism. 
As  regards  abscess  in  ostitis  of  the  vertebral  cohimn,  it  may  be  said  that 
incision  and  drainage  are  generally  indicated,  whether  occurring  on  the 
back,  in  the  way  of  the  apparatus,  or  pointing  near  the  groin  (psoas 
abscess).  Fresh  air,  well-selected  articles  of  food,  and  tonics,  are  essen- 
tial. In  the  severer  cases,  in  which  a  myelitis  is  developed  from  compres- 
sion by  the  products  of 

inflammation,    potassium      rfipv^ ~™^ = — — —f    ^ 

iodide,  in  full  and  contin-       "   ^ ■--■^-^  ■       ~     "  * 

ued  doses,  is  recommend- 
ed by  Professor  Gibney. 
In  all  cases  where  the  re- 
cumbent posture  is  as- 
sumed, an  effort  should 
be  made  to  keep  the  pa- 
tient on  the  back,  with  a  pillow  so  arranged  that  the  spinal  column  is 
bent  well  backward,  and  the  pressure  on  the  bodies  in  this  way  partially 
relieved.  The  suspensory  cradle  of  Reeves  (Fig.  690)  will  accomplish 
this  end  more  successfully.  A  splint  or  shell  is  made  of  gutta-percha  or 
sole-leather,  and  molded  accurately  to  the  back,  from  the  sacrum  to  the 
neck.  With  this  held  in  position  by  a  roller,  the  patient,  while  lying 
down,  is  supported  by  the  swing,  as  shown  in  Fig.  690. 

Spina  Bifida.— This  condition  results  from  a  failure  of  development 
in  the  laminae  and  spines  of  one  or  more  of  the  vertebrae.  Through  the 
opening  left  by  this  incomplete  closure  of  the  bony  canal  the  membranes 
of  the  cord  are  protruded,  forming  a  sac  of  variable  size,  which  is  dis- 


FiG.  690. — Eeeves's  suspensory  cradle.     (After  Eeeves.) 


800  A  TEXT-BOOK   ON    SURGERY. 

tended  by  the  cerebro-spinal  fluid.  The  cord  itself  may  be  wholly  or  in 
part  spread  out,  and  compressed  against  the  sac. 

Spina  bifida  is  met  with  most  frequently  in  the  lumbo- sacral  re- 
gion, next  in  frequency  in  the  neck,  rarely  elsewhere.  One  fissure  may 
exist  below  and  one  above  in  the  same  child,  though  it  is  very  rarely 
multiple. 

The  tumor  may  vary  in  size  from  one  inch  to  six  or  eight  inches  in  the 
longest  diameter,  and  may  be  sessile  or  pedunculated.  It  is  elastic  to  the 
touch,  and  is  usually  covered  by  the  integument,  which  is  thinner  than 
normal.  In  some  instances  the  skin  is  wanting  over  the  mass,  the  pro- 
truding dura  mater  forming  the  outside  covering  of  the  mass. 

The  character  of  the  swelling  may  be  recognized  by  its  congenital 
origin,  its  location  in  the  median  line  of  the  back,  almost  always  in  the 
lumbo-sacral  region,  its  smooth  contour,  elasticity,  and  chiefly  by  its 
variable  size.  It  becomes  larger  and  more  tense  during  the  act  of  crying, 
and  by  pressure  its  contents  may  in  part  be  forced  back  into  the  spinal 
cord  and  ventricles  of  the  brain.  Convulsive  movements  may  follow  too 
great  and  prolonged  compression  of  the  tumor.  The  prognosis  is,  as  a 
rule,  very  unfavorable.  Ulceration  of  the  integument  over  the  mass,  fol- 
lowed by  rupture  of  the  sac,  is  apt  to  occur,  usually  ending  in  death.  A 
recovery  after  this  accident  is  rare,  although  such  cases  are  reported. 
Or  the  tumor  may  remain  indefinitely  in  about  the  same  condition  as 
at  birth.  Paralysis,'  more  or  less  complete,  in  the  lower  extremities,  is 
the  riile. 

The  palliative  treatment  of  spina  bifida  consists  in  the  application  of 
moderate  compression  over  the  tumor,  at  the  same  time  protecting  the 
integument  from  all  irritation  and  injury.  This  plan  of  treatment  should 
be  followed  out  for  one  or  two  years,  unless  more  radical  measures  are 
indicated  by  the  failure  of  this  method  to  arrest  or  greatly  retard  the 
growth  of  the  swelling.  When  the  tumor  is  suddenly  increased  in  size 
and  tension,  temporary  benefit  may  be  obtained  by  drawing  off  a  small 
quantity  of  the  fluid..  From  3  j  to  3  j  may  be  withdrawn  by  the  aspira- 
tor. The  smallest  needle  should  be  employed,  and  the  contents  slowly 
evacuated.  The  quantity  of  fluid  to  be  removed  will  vary  with  the  size 
and  tension  of  the  tumor,  and  the  effect  produced  by  the  aspiration.  Two 
or  three  drachms  will  usually  suffice.  The  operation  may  be  repeated  as 
often  as  the  symptoms  demand.  It  is  advisable  to  introduce  the  needle 
through  the  side  of  the  tumor  rather  than  in  the  middle  line.  In  spina 
bifida  when  the  tumor  is  well  pedunculated  and  the  communication  be- 
tween the  sac  and  membranes  of  the  cord  is  not  large,  a  cure  may  be 
effected  by  the  method  of  Morton,  which  consists  in  the  injection  of  the 
following  solution  :  iodine,  grs.  x  ;  iodide  of  potassium,  grs.  xxx  ;  glycer- 
ine, §j.  From  5ss  to  3]  or  more  of  the  fluid  is  withdraA\Ti  from  the 
sac,  and  from  3ss.  to  3iij  of  the  iodine  solution  injected,  and  the  punct- 
ure covered  with  collodion.  This  operation  may  be  repeated  if  necessary. 
When  the  communication  between  the  sac  and  the  spinal  cord  is  wide, 
and  the  tumor  is  sessile,  operative  interference  is  not  indicated. 


DEFORMTTIES   OF   THE  LOWER  EXTREMITY.  801 


HEFOS DUTIES   OF  THE  LOWER   EXTSEJIITT. 

The  deformities  of  tlie  lower  extremity  may  be  divided  into  those — 
1,  of  the  coxo-femoral  region ;  2,  of  the  shaft  of  the  femur  in  its  en- 
tirety ;  3,  of  the  condyles ;  4,  of  the  tibia  and  fibula  ;  5,  of  the  tarsus 
and  metatarsus  :  and,  6,  of  the  phalanges. 

In  this  classification,  distortions  of  the  pelvis,  such  as  in  malacosteon 
and  rachitis,  are  excluded,  since  they  concern  the  obstetrician  rather  than 
the  surgeon. 

At  the  Tiip  there  may  exist  preternatural  mobility,  or  partial  or  com- 
plete immobility  with  malposition.  Preternatural  mobility  may  be  due 
to  the  following  causes  :  Ai-rest  of  development  in  the  bones  which  form 
the  acetabulum  ;  congenital  failure  of  development  of  the  head  of  the 
femur,  or  atrophy  of  this  portion  ;  to  both  of  these  conditions  combined  ; 
abnormal  length  of  the  capsular  ligament,  and  absence  of  the  ligamen- 
tum  teres. 

Immobility  with  malposition  results  from  inflammation  of  the  Joint 
and  anchylosis,  with  or  without  destructive  ostitis  and  loss  of  substance. 
Contraction  of  the  psoas  and  iliacus  or  other  muscles  about  the  hip 
which  are  not  overcome  before  anchylosis  ensues  is  the  chief  cause  of 
deformity.  Dislocation  with  failure  at  reduction  always  induces  de- 
formity, and  the  same  is  true  of  fracture  when  not  properly  treated. 

In  preternatural  mobility  at  the  hip-joint  (congenital  dislocation)  the 
symptoms  are  chiefly  a  peculiar  rolling  gait,  or  osciUatiou  to  right  and 
left  in  the  act  of  walking,  especially  when  the  deformity  is  bilateral. 
"While  standing  erect,  the  trochanters  will  be  closer  to  the  iliac  crest 
than  normal,  which  condition  can  be  accurately  determined  by  Xela- 
ton's  or  Bryant's  test.  In  these  cases  the  anterior  convexity  of  the  curve 
in  the  lumbar  region  is  exaggerated,  giving  the  patient  a  sway-back  ap- 
pearance. If  extension  is  made  fi'om  the  feet,  while  the  trunk  is  fixed 
in  the  recumbent  posture,  the  length  of  the  patient  will  be  considerably 
increased  over  that  measured  in  the  erect  position.  Absence  of  the 
head  of  the  femur  may  be  determined  by  palpation  with  outward  rota- 
tion. Perforation  of  the  acetabulum  may  also  be  made  out  by  digital 
exploration  per  rectum. 

Treatment. — Locomotion  in  some  cases  may  be  much  improved  by 
persistent  elf  ort  on  the  part  of  the  patient  to  train  the  muscles  to  hold 
the  femur  well  up  in  the  acetabulum  in  the  act  of  walking.  In  this  man- 
ner the  rolling  character  of  gait  may  be  in  great  part  con-ected.  One  im- 
portant indication  in  the  treatment  of  these  cases  in  children  is  to  keep 
the  head  of  the  femur  from  too  great  pressure  against  the  soft  structures 
placed  in  the  bottom  of  the  cavity  of  the  acetabulum.  The  double  hip- 
splint  of  Dr.  Sayre  will  accomplish  the  necessary  extension,  while  locomo- 
tion may  be  effected  by  crutches,  or  Dr.  Case's  carriage. 

In  anchylosis  at  the  hip  with  malposition  the  thigh  is  generally  flexed 
upon  the  abdomen  and  adducted  with  outward  rotation.  When  destruc- 
tive osteo-arthritis  has  occurred  the  trochanter  wiU  be  seen  nearer  to  the 
51 


802 


A  TEXT-BOOK  ON  SURGERY. 


iliac  crest  than  on  the  sound  side,  a  condition  which  does  not  exist  when 
the  anchylosis  is  simply  due  to  muscular  contractions. 

On  account  of  muscular  rigidity  the  exact  condition  of  anchylosis  can 
not  usually  be  determined  without  ether  narcosis.  A  certain  degree  of 
mobility  is  present  as  a  rule. 

Treatment. — When  the  malposition  is  such  that  usefulness  is  im- 
paired, or  comfort  interfered  with,  an  effort  to  relieve  the  deformity  by 
operation  is  justifiable,  provided  that  all  local  inflammatory  symptoms 
are  absent  and  that  the  general  condition  of  the  patient  is  such  that  no 
risk  is  incurred  by  the  procedure.  Under  ordinary  conditions  the  ojDera- 
tion  is  not  attended  with  danger. 

In  osteotomy  at  the  hip  for  the  relief  of  deformity  three  procedures 
may  be  entertained  :  Section  of  the  neck  of  the  femur,  just  above  the 
great  trochanter  (Adams,  Fig.  691) ;  the  inter- trochanteric  section  of 
Sayre  (Fig.  692) ;  or  the  sub-trochanteric  operation  of  Gant  (Fig.  693). 


Fig.  691. — Adams's  line  of  sec- 
tion.   (After  Poore.) 


Fig.  692. — Sayre's  inter-trocl}an- 
terio  line  of  section. 


Fig.  693.— Gant's  sub-tvoclianteric 
line  of  section.     (After  Poore.) 


The  objections  to  Adams's  line  of  section  is  that  often,  on  account  of  dis- 
appearance of  the  head  and  neck  of  the  bone,  it  is  impossible  ;  and,  sec- 
ondly and  chiefly,  if  disease  has  existed  at  the  joint,  this  line  of  section 
is  so  near  the  old  seat  of  osteo-arthritis  that  the  process  of  inflammation 
may  be  re-established.  In  anchylosis,  without  osteoarthritis  at  the  hip, 
it  is  to  be  preferred.  In  the  vast  majority  of  cases,  Gant's  section — just 
at  the  lower  portion  of  the  lesser  trochanter — is  preferable.  The  objects 
to  be  accomplished  are,  a  section  of  the  bone  at  this  point  at  a  right 
angle  to  the  axis  of  the  shaft,  rotation  of  the  femur  into  its  normal  posi- 
tion, and  abduction. 

Siib-trochanteric  Osteotomy  at  tlie  Hip. — The  patient  is  placed  on  the 
sound  side,  so  that  the  femur  to  be  divided  is  well  exposed.  The  strict 
details  of  antisepsis  should  be  carried  out. 

The  upper  surface  of  the  great  trochanter  is  felt,  and  the  femur 
grasped  between  the  thumb  and  finger.     Upon  the  outer  portion  of  the 


SUB-TROCHANTERIC   OSTEOTOMY  AT   THE   HIP. 


803 


femur  an  incision  is  made,  commencing  about  one  inch,  below  tlie  most 
superior  surface  of  tbe  trochanter  major,  and  extending  downward  about 
one  inch  and  a  half.  When  the  bone  is  exposed,  the  wound  is  held 
open  by  retractors,  and  the  bluntest  of  Macewen's  bone-chisels  introduced 
flatwise  with  the  incision  until  the  bone  is  reached,  when  it  is  turned  so 
that  the  cutting  edge  is  across  the  axis  of  the  femur.  In  a  child  twelve 
years  old  the  lower  portion  of  the  lesser  trochanter  (the  line  of  section) 
is  about  one  and  a  half  inch  below  the  tip  of  the  great  trochanter. 

While  the  limb  is  steadied  by  an  assistant,  a  few  blows  with  the 
mallet  drives  the  chisel  through  the  outer  rim,  when  a  thinner  chisel  is 
inserted  and  the  bone  cut  from  one  half  to  three  fourths  through.  Grasp- 
ing the  thigh  near  the  knee  with  one  hand,  while  the  other  steadies  the 
part  above  the  section,  the  remaining  portion  is  readily  fractured  by 
carrying  the  thigh  toward  the  median  line.  The  wound  is  now  thor- 
oughly irrigated  and  closed  with  catgut  sutures,  leaving  a  bone-drain  out 
at  the  lower  angle.  A  sublimate  dressing 
is  applied.  The  thigh  is  rotated  slightly 
inward,  abducted  to  about  five  degrees  fi-om 
the  axis  of  the  spine,  and  flexed  on  the  ab- 
domen so  that  the  axis  of  the  femur  joins 
that  of  the  body  at  an  angle  of  fifteen  de- 
grees (Fig.  694).  If  in  the  position  of  de- 
formity the  thigh  is  abducted — a  condition 
which  rarely  exists — the  corrected  position 
should  be  that  of  adduction  about  five  de- 
grees beyond  the  normal.  The  after-treat- 
ment is  the  same  as  for  fracture  at  this 
point,  namely,  Buck's  extension  and  Ham- 
ilton's long  splint  (page  310). 

In  order  to  secure  the  necessarj'  five  de- 
grees of  abduction,  the  padding  to  the  splint 
should  be  made  several  inches  thicker  op- 
posite the  acetabulum  than  at  the  knee,  and 
the  thigh  and  leg  should  be  elevated  upon 
pillows  enough  to  secure  the  fifteen  degrees 
of  flexion  required.  When  consolidation 
occurs  with  the  extremity  in  this  position, 
locomotion  is  good  and  more  comfort  ex- 
perienced in  the  sitting  posture  than  when 
the  leg  is  perfectly  straight.  At  the  end  of 
four  or  five  weeks  the  patient  may  be  al- 
lowed to  go  about  on  crutches,  and  in  eight  or  ten  weeks  to  walk  with- 
out them. 

The  result  to  be  achieved  is  osseous  reunion  at  the  point  of  fracture 
with  the  limb  in  the  improved  position.  A  false  or  new  joint  is  not 
desirable.  Esmarch's  bandage  is  not  essential  in  the  performance  of  the 
operation,  although  it  may  be  employed  if  desired.  The  haemorrhage  is 
usually  slight,  and  a  few  catgut  ligatures  readily  control  all  bleeding 


694. — The  proper  position  of  the 
extremity  after  sub-trochanteric  os- 
teotonry.     (After  I'oore.) 


804  A  TEXT-BOOK  ON  SURGERY. 

points.  The  free  incision  advised  is  safer  than  to  use  the  osteotome 
through  a  narrow  wound.  Forcible  breaking  up  of  adhesions  or  fracture 
at  the  Joint  is  not  permissible.  Adams's  section  is  made  through  an  in- 
cision in  the  line  advised  for  hip-joint  exsection.  Its  center  should  cor- 
respond to  a  point  just  above  the  great  trochanter.  The  chisel  should 
be  preferred  to  the  saw  in  making  the  section,  on  account  of  the  bone- 
dust  and  detritus  left  by  this  latter  instrument. 

Sayre's  line  is  half-way  between  Adams's  and  Gant's  lines.  The 
bone  should  be  divided  squarely  across.  The  attempt  to  form  an  arti- 
ficial ball-and-socket  joint  by  making  a  concavity  in  the  upper  fragment, 
or  rounding  off  the  upper  extremity  of  the  lower  fragment,  is  not  justi- 
fiable, because  it  prolongs  the  operation,  and  is  apt  to  be  followed  by 
necrosis,  with  ultimate  anchylosis.  It  is  better  to  accomplish  reunion 
at  once. 

The  deformities  of  the  shaft  of  the  femur  are  also  congenital  and 
acquired.  An  occasional  congenital  malformation  is  due  to  failure  of 
development  of  this  bone  in  its  long  axis.  The  femur  may  not  be  more 
than  six  inches  in  length,  while  the  tibia  and  fibula  are  normal  in  devel- 
opment. As  a  consequence  of  rickets,  the  femur  is  occasionally  curved 
outward,  causing  genu  varum,  or  bow-legs,  although,  as  wUl  be  seen 
later,  the  bones  of  the  leg  are  chiefly  involved  in  this  deformity. 

Shortening,  with  or  without  angular  malposition,  is  sometimes  seen 
after  badly  united  fractures. 

For  the  relief  of  these  deformities  osteotomy  and  osteoclasis  may  be 
done  when  the  deformity  is  sufficient  to  justify  the  operation.  In  oste- 
otomy the  incision  should  be  along  the  anterior  and  external  aspect  of 
the  thigh  farthest  removed  from  the  vessels.  The  only  artery  of  im- 
portance here  is  the  descending  branch  of  the  external  circumflex.  Oste- 
oclasis is  not  permissible  unless  the  fracture  can  be  effected  by  maniial 
force.  In  recent  and  badly  united  fractures,  and  in  rachitic  subjects,  this 
may  be  done.  The  osteotome  is  preferable  to  the  osteoclast.  In  over- 
lapping fractures,  with  marked  shortening  (two  to  five  inches),  if  the 
union  is  not  angular,  the  deformity  may  be  corrected  and  lateral  spinal 
curvature  obviated  by  a  compensating  high  shoe.  If  for  {esthetic  reasons 
the  patient  insists  upon  it,  a  section  may  be  taken  from  the  sound  femur 
and  the  ends  brought  together,  as  was  done  by  Weir  in  one  instance. 
The  conditions  which  will  justify  this  procedure  are,  however,  rare. 

Occasionally  overlapping  and  badly  united  fractures  of  the  thigh  will 
be  met  with  in  which  the  callus,  which  persists,  is  so  extensive  that 
operation  at  the  seat  of  fracture  is  impossible. 

The  deformities  of  the  lower  extremity  of  the  femur  are  those  of 
hypertrophy  or  elongation  of  one  or  the  other  condyle.  The  outer  condyle 
is  only  exceptionally  enlarged.  The  consideration  of  these  pathological 
changes  belongs  properly  to  genu  valgum  and  varum. 

Oenu  Valgum. — When  a  normal  subject  stands  erect,  the  inclination 
of  the  femur  of  each  side  is  inward  and  toward  its  fellow,  until  the  inter- 
nal condyles  are  almost  in  contact.  In  other  words,  by  actual  measure- 
ment in  a  descent  of  eighteen  inches  from  the  head  to  the  condyloid 


GENU  VALGUM. 


805 


extremity,  a  separation  of  seven  inches  between  the  acetabula  is  reduced 
to  three  and  a  half  inches  from  center  to  center  at  the  knee.  Tiiis 
obliquity  is  slightly  increased 
in  females,  owing  to  the  broad- 
er development  of  the  pelvis. 

If  the  articular  facets  of  both 
tibige  are  brought  firmly  and 
evenly  in  contact  with  the  con- 
dyles of  thie  femur,  it  will  be 
seen  that  the  axis  of  the  tibia  is 
parallel  with  that  of  the  spine. 

Any  outward  deviation  of 
this    parallelism    of    the    tibia  /      i0       '^^  ^' 

with  the  axis  of  the  body  con- 
stitutes the  deformity  known  as 
genu  tialgmn,  knock-knee,  or 
in-knee  (Pig.  695). 

Knock-knee  may  occur  on 
one  or  both  sides,  in  both  sexes 
and  at  all  ages.     In  exceptional        ^  ^         ,        ^    ,  , 

Fig.  695. — Genu  valgum — Knock-knee  or  in-knee. 

instances  genu  valgum  may  ex-  (Alter  Poore.) 


)6. — Genu  valguc 

patient,  in  Mount  Sinai  Hospital. 


Fig.  697.— The  same,  atter  osteotomv  ot  both 
femora.     (The  author's  case.) 


ist  on  one  side  and  varum  on  the  other,  as  shown  in  Figs.  696  and  697. 
Knock-'knee  is  usually  acquired;  occasionally  congenital.  It  is  most 
frequently  seen  in  children  and  young  adults  suffering  from  an  acquired 


806  A  TEXT-BOOK   ON  SURGERY. 

or  hereditary  dyscrasia.  As  to  the  causes,  we  must  look  cMefiy  to 
changes  in  the  bones  at  or  near  the  Isnee-joint.  Any  interference  with  the 
normal  jarocesses  of  nutrition  and  development  in  the  bones  will  account 
for  most  cases  of  knock-knee,  and  the  chief  pathological  condition  is  either 
that  of  rachitis,  or  one  so  closely  allied  to  it  that  a  distinction  is  difficult. 

The  most  classical  osseous  lesion  in  genu  valgum  is  the  enlargement 
of  the  internal  condyle  as  compared  to  the  external,  and  the  resulting 
increase  of  the  normal  obliquity  of  the  tibio-femoral  articulation.  This 
increased  obliquity  may  be  due  to  hypertrophy  of  the  inner  condyle  ;  or 
to  hypertrophy  of  the  inner  half  of  the  upper  tibial  epiphysis ;  to  atrophy 
of  the  outer  condyle,  or  atrophy  of  the  outer  half  of  the  upper  tibial 
epiphysis  ;  to  a  combination  of  two  or  more  of  these  conditions  ;  to  a 
curve  of  the  femur  (convexity  inward)  from  rickets,  and  to  a  like  curve 
of  the  tibia  and  fibula. 

There  is  no  anatomical  reason  why  the  internal  condyle  should  enjoy 
a  better  nutrition  and  greater  development  than  the  outer.  There  is, 
however,  a  very  good  mechanical  explanation  in  this,  that  by  reason  of 
the  marked  obliquity  of  the  femoral  axis  and  the  perpendicular  direction 
of  the  tibial  shaft  when  the  subject  is  standing  erect,  the  line  of  gravity 
brings  the  greater  weight  upon  the  outer  facet  of  the  tibia  and  the  cor- 
responding condyle  of  the  femur.  The  distribution  of  this  pressure 
equally  over  the  entire  articular  surface  belongs  to  the  muscles  control- 
ling this  joint ;  but  owing  to  the  excessive  number  and  greater  power  in 
the  adductor  as  compared  to  the  abductor  grouj),  the  internal  obliquity  is 
maintained  and  the  pressure  upon  the  outer  articular  surfaces  increased. 
In  the  rachitic  condition  the  bones  are  softened,  and  become  distorted 
under  pressure,  and  as  a  result  of  muscular  action,  while  such  deformi- 
ties are  resisted  by  the  normal  bones. 

Knock-knee  from  incurvation  of  the  shaft  of  the  os  femoris  alone  is 
exceedingly  rare.  When  not  due  to  abnormal  changes  in  the  condyles, 
the  cause  of  this  deformity  will  usually  be  found  in  rachitic  disease  of 
the  tibia  and  fibula,  in  which  these  bones  are  bent  inward  at  the  middle 
or  lower  third.  The  princijDal  changes  in  the  soft  parts  are  elongation  of 
the  internal"lateral  ligaments,  and  a  contractured  condition  of  the  biceps 
and  popliteus  muscles. 

Symptoms. — The  symptoms  of  knock-knee  vary  in  different  stages  of 
the  deformity.  The  approximation  of  the  knees  is  a  less  noticeable 
feature  than  the  divergence  of  the  tibiae.  With  the  lower  extremities 
fully  extended,  and  the  knees  in  contact,  it  will  be  noticed  that  the  inner 
malleoli  are  separated  from  a  few  inches  to  a  foot  or  more.  When  the 
lesion  is  due  to  changes  in  the  inner  condyle  of  the  femur,  it  will  be 
observed  that,  if  the  leg  is  flexed  upon  the  thigh  at  an  angle  of  90°,  the 
deformity  is  less  apparent ;  and  if  complete  flexion  is  made  in  mild  cases 
of  in-knee,  it  will  disappear  altogether ;  i.  e.,  the  tibia  in  extreme  flexion 
will  be  parallel  with  the  femur.  The  patella  is  displaced  outward,  and 
locomotion  is  more  or  less  impaired.  Pain  is  often  present,  from  the 
unnatural  strain  upon  the  tissues,  and  fatigue  with  the  slightest  exertion 
is  often  noticed. 


GEXTJ  YALGOI. 


807 


The  diagnosis  rests  npon  the  recognition  of  the  symptoms  just 
detailed,  and  the  prognosis  is  generally  favorable  when  judicions 
and  persistent  treatment  is  instituted.  Constitutional  remedies  and 
mechanical  appliances  are  indicated  early  in  the  disease,  and  opera- 
tive interference  is  Justifiable  when  mechanical  treatment  can  not  effect 
a  cure. 

The  first  indication  is  met  in  out-of-door  life,  good  food,  diversion, 
tonics,  cod-liver  oil,  and  the  hypophosphites  of  lime  and  soda. 

The  mechanical  treatment  should  be  insisted  upon  in  all  cases  of  chil- 
dren in  which  the  deformity  is  not  exaggerated,  and  should  be  persisted 
in  for  several  years,  if  necessary.  Any  mechan- 
ism which  is  applicable  in  this  deformity  must 
afford  a  fixed  point,  opposite  to  and  on  the  ex- 
ternal aspect  of  the  region  of  the  knee-joint,  from 
which  constant  traction  may  be  made.  The  appa- 
ratus of  Prof.  Sayre  (Fig.  698j  will  be  found  of 
great  use  in  meeting  the  chief  indications.  It 
consists  of  a  pelvic  belt  of  steel,  padded  so  as 
not  to  excoriate,  and  a  bar  of  steel  hinged  at  the 
knee,  and  passing  down  from  the  belt  to  the  sole 
of  the  shoe,  where  it  is  fastened,  as  in  the  long 
hip-spKnt  ali'eady  described. 

Opposite  each  knee,  and  just  above  and  be- 
low the  joiuts — in  order  to  distribtite  the  press- 
ure over  a  wider  area,  and  thus  prevent  chafing  or 
excoriations — are  padded  belts  or  bands  which 
surround  the  limb  ;  these  are  attached  to  the 
side-bars,  and  may  be  tightened  at  will  iu  exer- 
cising the  required  traction  to  overcome  the  deformity.  Elastic  tension 
by  means  of  rubber  bands  or  webbing  may  also  be  utilized  in  this  man- 
ner. The  hinges  at  the  knees  allow  the  patient  to  bend  these  joints  in 
walking  and  when  it  is  desired  to  assume  the  sitting  posture.  The 
instrument  should  be  worn  during  the  waking  hours,  and  at  night  it 
will.be  advisable  to  make  extension  from  both  legs  by  Buck's  method. 
The  cost  of  this  apparatus  places  it  beyond  the  reach  of  many  patients, 
and  in  this  class  of  cases  renders  early  operative  interference  more  jus- 
tifiable. 

Osteotomy  of  the  femur  for  the  correction  of  chronic  cases  of  genu 
valgtim  is  an  operation  practically  free  from  danger,  and  jaelds  excel- 
lent results.  The  section  should  be  made  above  the  joint,  and  away 
from  it  a  sufiicient  distance  to  avoid  all  danger  of  entering  the  articula- 
tion or  injuring  the  epiphysis.  Linear  section  should  be  preferred,  since 
it  is  simpler  than  cttneiform  osteotomy,  and  is  equal  to  the  correction  of 
aU.  cases  excepting  those  in  which  there  is  extreme  angtilarity  at  the  seat 
of  deformity.  Such  conditions  rarely,  if  ever,  occur  in  the  femur.  The 
older  operations  of  Ogston,  Keeves,  Chiene,  and  Macewen,  which  in- 
volved the  joiut,  are  practically  discarded.  They  are  objectionable  in 
this,  that  they  invade  the  joint  and  endanger  the  functions  of  this  im- 


— Sayre's  apparatus  foi 
the  correction  of  knock-knee. 
(After  Sayre. J 


A  TEXT-BOOK   ON  SURGERY. 


portant  articulation.*  Transverse  section  above  the  epiphyseal  line,  from 
the  outside  (MacCormac)  or  inner  side  (Macewen),  should  be  preferred 
(Pig.  703). 

-  Macewen'' s  Operation.— la  this  procedure  it  is  intended  to  divide  the 
femur  at  a  right  angle  to  its  axis  through  two  thirds  to  three  fourths  of 
its  thickness,  at  a  point  well  above  the  level  of  the 
lower  epiphysis.  In  a  child  ten  years  old  the  line 
of  section  should  be  one  and  three  quarter  inch 
above  the  most  dependent  portion  of  the  articular 
surface  of  the  internal  condyle,  and  in  an  adult  two 
and  a  half  inches. 

Strict  antiseptic  precautions  should  be  taken. 
If  Esmarch's  bandage  is  applied  as  high  as  the  mid- 
dle of  the  thigh,  the  wound  will  be  kept  dry  and 
the  operation  greatly  facilitated.  Flex  the  leg  on 
the  thigh  and  rotate  the  thigh  outward  so  as  to 
bring  the  inner  aspect  of  the  joint  upw^ard.  Make 
an  incision  one  inch  long,  following  the  direction  of 
the  internal  condyloid  ridge.  The  center  of  this  in- 
cision should  be  opposite  the  point  of  section  above 
given.  The  internal  sphenous  vein  and  the  anas- 
tomotica  magna  artery  should  be  avoided,  and  the  tubercle  for  the 
insertion  of  the  tendon  of  the  adductor  magnus  felt.  As  soon  as  the 
bone  is  reached  the  chisel  is  carried  down  to  it,  parallel  with  the  incision, 
and  immediately  turned  with  its  cutting  edge  at  a  right  angle  to  the  axis 
of  the  femur.  The  inner  and  anterior  shell  of  compact  tissue  shoxild  be 
first  divided,  and  when  the  jDosterior  portion  is  cut  through  the  osteotome 
should  be  directed  to  the  front  so  that  when  struck  with  the  mallet  it  will 
be  carried  away  from  the  vessels.  As  soon  as  the  bone  is  cut  through  two 
thirds  of  its  thickness,  the  remaining  piece  may  be  fractured  by  grasping 
the  limb  above  and  below  the  section,  and  using  the  other  hand  for  a 
fulcrum  and  the  leg  as  a  lever,  which  is  carried  outward.  As  soon  as 
the  bone  snaps,  the  leg  is  handed  to  an  assistant,  who  is  directed  to  steady 


Fig.  703. — a,  MacCormac' 
line,    b,  Macewen' 8  line, 


Figs.  699-702.     (After  Poore.) 


Fig.  699.— Ogston. 


Fig.  700.— Eeeves, 


Fig.  702. — ^Macewen. 


GENU  VARUM. 


809 


it  by  makiBg  strong  extension.  The  wound  should  now  be  irrigated  with 
1'3000  sublimate,  a  sponge  applied  as  a  compress,  held  in  place  by  a  roller, 
and  the  tourniquet  removed.  In  five  minutes,  if  no  bleeding  of  impor- 
tance occurs,  the  sponge  may  be  removed  and  a  dressing  of  iodoform 
and  sublimate  gauze  applied.  The  limb  should  be  brought  into  the 
straight  position  by  extension,  and  steadily  held  untU  a  plaster-of-Paris 
bandage  is  put  on  and  hardened.  This  dressing  is  allowed  to  remain  for 
four  or  five  weeks,  as  in  simple  fracture,  when  it  is  removed,  and  passive 
motion  made  at  the  joint.  It  is  reapplied  for  a  week  longer,  and  then,  as 
a  rule,  may  be  discontinued.  MacCormac's  x^rocedure  is  jDractically  the 
same  as  the  above,  with  the  exception  that  the  section  is  made  fi-om  the 
outer  side  of  the  femur.  Of  these  two  operations  the  incision  from  the 
outer  side  (MacConnac's)  is  preferable,  for  the  reason  that  there  are  no 
vessels  in  the  way.  On  the  inner  side  the  long  saphenous  veiu  and  the 
anastomotica  magna  artery  are  endangered.  Moreover,  it  does  not  matter 
from  which  side  the  bone  proper  is  divided,  as  far  as  the  correction  of  the 
defoi-mity  is  concerned.  When  the  tibia  and  fibula  are  involved  in  the 
deformity,  section  of  these  bones  may  be  requii'ed  at  the  same  or  a  sub- 
sequent operation. 

Genu  Varum. — In  bow-leg,  or  outward  curvature  of  the  lower  ex- 
tremity, one  or  both  members  may  be  involved.     The  bones  of  the  leg 
are  usually  alone  involved,  although 
in  some  instances  the  femur  may  take 
part  in  the  deformity  (Fig.  704). 

The  principal  cause  of  bow-legs  is 
rickets,  the  softened  bones  yielding  to 
the  weight  of  the  body  or  to  muscu- 
lar contractions.  Genu  varum  is  usu- 
ally met  with  in  childhood,  but  may 
occur  in  adults  who  are  rachitic.  In 
treatment,  the  indications  are  the  same 
as  for  knock-knee.  The  adjustment 
of  any  mechanical  apparatus  is,  how- 
ever, more  difficult.  Splints  should 
be  adjusted  to  prevent  further  deform- 
ity, or  the  patient  should  be  prevent- 
ed from  bringing  the  weight  of  the 
body  upon  the  diseased  bones.     In 

the  mean  whUe  every  effort  should  be  made  to  correct  the  dyscrasia. 
As  long  as  the  bones  remain  in  the  softened  condition  of  rickets,  oper- 
ative interference  is  not  indicated.  Osteotomy  of  the  tibia  and  fibula 
at  the  point  where  the  outward  curve  is  most  pronounced  will,  in  the 
majority  of  instances,  correct  the  deformity.  In  extreme  cases  it  may 
be  necessary  to  make  sections  at  two  or  more  points.  If  the  femur 
is  involved  it  shoidd  also  be  divided,  although  this  complication  will 
rarely  be  met  with.  The  details  of  the  operation  and  the  after-treatment 
are  practically  the  same  as  for  genu  valgum. 

Osteoclasis  should  be  substituted  for  osteotomy  only  in  those  cases 


Fig.  TOi. — Genu  varum,  or  bow-legs. 
(^After  Poore.) 


810 


A  TEXT-BOOK  ON  SURGERY. 


in  which  the  fracture  may  be  accomplished  with  little  force  and  with 
the  hands  of  the  operator.  It  is  objectionable  when  performed  with  the 
osteoclast,  for  the  reason  that  the  soft  tissues  are  bruised  to  an  extent 
which  does  not  occur  in  osteotomy.  Moreover,  the  line  of  fracture  can 
not  be  directed  with  the  same  accuracy  as  in  cutting  with  the  chisel. 
The  necessity  for  the  exclusion  of  air  no  longer  exists  in  the  use  of  sub- 
limate irrigation  and  the  antiseptic  dressing. 

Anchylosis  at  the  Knee,  with  Malposition. — For  the  correction  of 
this  deformity  osteotomy  is  at  times  performed.  When  the  degree  of 
maljjosition  is  extreme,  it  may  become  necessary  to  divide  the  femur  at 
a  point  from  three  to  four  inches  above  the  most  dependent  portion  of 
the  articular  surface  of  this  bone.  If  after  this  section  the  limb  can  not 
be  brought  out  straight,  division  of  the  tibia  just  below  the  tuberosity 
may  be  done.  Exsection  of  the  knee  is,  however,  a  preferable  operation; 
and,  since  in  modern  practice  the  danger  of  this  precedure  is  so  greatly 
diminished,  it  is  believed  that  the  operation  through  the  articulation 
will  supersede  section  of  the  bone  in  continuity. 

Talipes. — Club-foot  is  a  deformity  in  which  there  exists  either  an 
abnormal  relation  between  the  bones  of  the  foot  to  each  other,  or  to  the 
tibia  and  fibula.  There  are  six  simple  and  several  compound  forms  of 
talipes.  The  simple  varieties  are  talipes  equinus,  calcaneus,  varus, 
valgus,  cavus,  and  ,planus.  Among  the  compound  forms  are  those  of 
equino-valgus,  equino'-varus,  calcaneo-valgus,  calcaneo-varus,  etc. 

In  talipes  eqiunus  the  heel  is  drawn  up,  and  the  weight  of  the  body 
falls  upon  the  plantar  aspect  of  the  metatarsus,  the  toes  and  phalanges  ; 
the  gastrocnemius  and  soleus  are  shortened,  the  tendo  Achillis  tense, 
and  in  extreme  cases  the  heel  can  not  be  brought  down  to  the  ground. 


Fig.  705.  Fis.  706. 

Congenital  talipes  eqiunus.     (After  Cliureliill.) 


Callosities  are  formed  upon  the  sole  of  the  foot  along  the  metatarso- 
phalangeal line.  When  paralysis  of  the  anterior  muscles  of  the  leg  has 
taken  place,  the  toes  are  turned  under,  as  in  Fig.  708.     In  this  condition 


TALIPES. 


811 


there  are  atrophy  and  complete  loss  of  power  in  the  tibialis  anticus,  pero- 
neus  tertius,  extensor  longus  digitorum,  and  extensor  poUicis  muscles. 
Simple  talipes  equinus  is  not  of  very  frequent  occurrence,  since  it  is 


Fig    tot 
Acquired  talipes  equinus.     In  Fig 


708  there  has  occurred  complete  paralysis  of  the  extensor  muscles. 
(After  Churchill.) 


almost  always  complicated  with  inward  rotation  of  the  tarsus,  or  talipes 
equino-varus. 

Treatment. — When  complete  paralysis  has  not  occurred,  and  if  taken 
early,  talipes  equinus,  whether  congenital  or  acquired,  may  be  cured,  or 
marked  deformity  prevented,  by  the  institution  of 
proper  treatment.  Section  of  the  tendo  Achillis  is 
rarely  necessary  when  the  case  has  not  been  neglect- 
ed. The  propriety  of  tenotomy  can  be  determined  by 
the  degree  of  resistauce  met  with  in  the  effort  to  bring 
the  sole  of  the  foot  to  a  right  angle  with  the  axis  of 
the  leg.  If  this  can  not  be  accomplished,  or  if,  when 
the  tarsus  is  firmly  flexed  on  the  leg,  pressure  upon 
the  sural  muscles  produces  a  painful  and  marked 
spasm  (Sayre),  tenotomy  is  indicated,  es^Decially  in 
those  patients  who  can  not  afford  the  long-continued 
expense  of  mechanical  treatment,  and  who  of  neces- 
sity can  not  remain  long  in  the  hands  of  an  experi- 
enced surgeon.  In  simjjle  equinus  the  indications  are 
to  overcome  the  muscular  contraction  by  artificial  ap- 
pliances, and  to  restore  the  normal  tonicity  and  power  to  the  anterior 
tibial  group  of  muscle. 

When  a  child  is  bom  with  talipes  equinus  (and  all  forms  of  congenital 
club-foot  should  be  treated  from  birth),  deformity  of  the  bones  of  the 
foot,  and  the  too  great  stretching  or  elongation  of  the  anterior  muscles, 
may  be  prevented  by  the  following  simple  means :  Cut  a  piece  of  light 
board  as  wide  as  the  sole,  and  a  little  longer  than  the  foot,  and  cover  it 


Fig.  T09.— Bones  of  the 
foot  of  an  adult  with 
talipes  equinus.  (Aft- 
er Chance  and  Noble 
Smith.) 


812  A  TEXT-BOOK   ON   SURGERY. 

with  adhesive  plaster  in  such  a  way  that  the  sticking  surface  is  next  to 
the  skin.  This  is  laid  along  the  sole  of  the  foot,  to  which  it  is  fastened 
by  adhesive  strips,  and  a  light  bandage,  leaving  the  end  of  the  board  to 
project  a  little  beyond  the  toes.  From  the  end  of  the  board  traction 
may  be  made  by  a  strip  of  plaster  carried  upward  and  fastened  along 
the  front  of  the  leg  near  the  knee,  sufficient  tension  being  exercised  to 
draw  the  foot  into  its  natural  position.  Or,  if  deemed  necessary,  arti- 
ficial muscles  (rubber  tubing)  may  be  attached  from  the  tip  of  the  board 
to  insertions  fastened  near  the  knee  on  the  antero-lateral  aspects  of  the 
leg.  The  apparatus  must  be  carefully  readjusted  whenever  it  becomes 
loose  or  causes  pain. 

When  the  patient  is  able  to  walk,  simple  cases  of  equinus  may  be 
corrected  by  wearing  a  stiff,  solid,  and  well-constructed  laced  shoe,  which 
will  hold  the  instep  well  down  and  keep  the  sole  of  the  foot  in  close 
contact  with  the  sole  of  the  shoe.  The  weight  of  the  body,  falling  upon 
the  anterior  portion  of  the  foot,  will  aid  in  carrying  the  heel  to  the 
ground  with  each  stej). 

In  more  obstinate  cases  the  Sayre  shoe  (Fig.  710)  more  nearly  meets 
the  mechanical  indications  than  any  other  apparatus.  When  there  is 
no  inversion  of  the  foot  (varus),  the  lateral  rub- 
ber muscle  /  ^  is  iinnecessary.  In  ordering  this 
shoe  it  is  advisable  to  send  to  the  instrument- 
maker  the  shoe  at  the  time  worn  by  the  pa- 
tient, and  with  this  the  distance  from  the  sole 
of  the  heel  to  the  upper  articular  margin  of  the 
tibia,  as  well  as  the  circumference  of  the  leg  at 
this  point.  To  this  may  be  added  the  measure- 
ments around  the  foot,  at  the  bases  of  the  toes, 
and  around  the  malleoli.  In  all  cases  of  talipes 
in  walking  children  and  adults,  it  is  important 
that  all  excoriations  be  healed  before  any  appli- 
ance is  adjusted. 
■n^rmtus—ca  rpj^g  xda-Si  must  uot,  however,  be  entertained 

Fia.  no.-^Sayre'i^duYootshoe.  ^j^^,.  ^^^  ^\^^\(,  application  of  the  shoe,  or  any 
mechanical  appliance,  will  correct  the  deformity. 
The  after-treatment  is  a  most  important  feature  in  these  cases.  Electrici- 
ty and  massage  are  important  adjuvants.  The  weaker  galvanic  current 
should  be  preferred,  the  positive  pole  being  placed  along  the  track  of 
the  nerve  which  supplies  the  affected  muscles,  while  the  negative  sponge 
is  carried  over  the  bellies  of  these  muscles.  The  application  should  be 
made  about  twice  each  week,  while  massage  should  be  emi)loyed  twice 
daily. 

In  those  cases  where  tenotomy  is  deemed  advisable,  the  operation  is 
performed  as  follows :  The  patient  being  placed  under  the  influence  of 
an  anaesthetic,  the  tarsus  is  Hexed  forcibly  upon  the  leg,  in  order  to  place 
the  tendo  Achillis  and  plantar  fascia  upon  the  stretch  ;  a  slight  puncture 
of  the  skin  is  then  made,  a  little  anterior  to  the  tendon,  and  on  the  inner 
side  of  the  leg,  slightly  above  the  malleolus  ;  this  opening  is  now  carried 


TALIPES   CALCANEUS. 


813 


to  the  edge  of  the  tendon  by  traction  upon  the  integument,  and  the 
tenotome  introduced,  with  its  flat  surface  toward  the  tendon.  The  ten- 
sion upon  the  tissues  is  now  relaxed,  and  the  edge  of  the  knife  turned 
toward  the  parts  to  be  divided ;  the  tarsus  is  flexed  strongly  ujjon  the 
leg,  and  the  tendon  again  made  tense,  when  the  knife  is  pressed  forward 
and  outward  through  the  tendon,  which  separates  with  a  very  audible 
snap.  The  thumb  of  the  operator  being  placed  over  the  tendon  exter- 
nally, acts  as  a  guide  and  supjDort,  preventing  the  blade  from  passing 
through  the  integument  and  causing  an  open  wound,  an  accident  which 
should  be  carefully  avoided.  As  soon  as  the  division  of  the  tissues  is 
efliected,  the  blade  of  the  knife  should  be  withdrawn,  flatwise,  and  the 
thumb  of  the  operator  slipped  over  the  slight  puncture,  which  is  at  once 
covered  with  one  or  two  strips  of  adhesive  plaster  ;  the  plantar  fascia  can 
be  divided  in  a  similar  manner,  if  desii'able,  the  whole  foot  being  then 
enveloped  in  cotton,  and  a  snug  roller  bandage  applied.  The  foot  is  now 
secured,  by  mechanical  appliances,  at  a  right  angle  to  the  leg,  as  hereto- 
fore described.  Division  of  the  extensor  tendons  of  the  toes  is  not  often 
required.  The  best  point  of  section  is  just  over  the  metatarso-phalangeal 
articulation. 

Talipes  Calcaneus. — In  this  rare  form  of  club-foot  the  toes  are  drawn 
upward  and  the  tarsus  flexed  upon  the  tibia ;  impairment  of  function 

exists  in  one  or  more  of  the  sural 
muscles  ;  the  tibialis  anticus,  pero- 
neus  tertius,  extensor  longus  digito- 
rum,  and  pollicis  are  shortened.  This 
deformity  may  be  either  congenital 


Fig.  711. — Congenital  talipes  calcaneus. 
(Alter  Churcliill.) 


Fig.  712. — Acquired  talipes  calcaneus. 
(After  Churchill.; 


or  acquired  (Figs.  711,  712).  It  is  usually  met  with  in  children,  or  may 
occur  at  any  period  of  life,  from  rupture  of  the  tendo  Achillis,  or  paral- 
ysis of  the  muscles  of  the  calf  of  the  leg,  ununited  fracture  of  the  os 
calcis,  etc.  In  this  condition  the  mechanical  and  surgical  appliances  and 
treatment  are  exactly  opposite  to  those  of  the  preceding  variety.  An 
ununited  section  of  the  tendo  Achillis  should  be  coiTected  by  cutting 
down  upon  this  tendon  at  the  seat  of  the  division,  freshening  the  divided 


814 


A  TEXT-BOOK   ON   SURGERY. 


ends,  and  sewing  them  together  with  silk  sutures.  Mild  cases  of  calca- 
neus may  be  relieved  by  the  wearing  of  a  well-fitting,  laced  shoe,  the 
weight  of  the  body  aiding  in  correcting  the  deformity.  When  the  toes 
can  not  be  brought  down  without  the  aid  of  additional  jjressure,  the 
apparatus  in  construction  similar  to  the  one  recommended  for  flat-foot 
can  be  applied.  The  object  to  be  obtained  is  to  elevate  the  heel  and 
dej)ress  the  toes  by  mechanical  means.  For  this  purpose,  the  shoe  as 
devised  by  Dr.  Sayre  (Fig.  713)  is  admirably  adaj^ted.  This  is  a  strong, 
laced  shoe,  with  steel  rods  running  Tip  on  either  side  of  the  leg  to  a 
collar  below  the  knee,  the  rods  being  hinged  at  the  ankle  to  allow  of 
free  motion  at  this  joint ;  from  the  heel  of  the  shoe  a  small  steel  spur  is 
seen,  to  which  is  secured  a  strong  piece  of  elastic,  passing  up  to  the 
collar  around  the  leg.  This  rubber  artificial  muscle,  taking  the  place 
of  the  gastrocnemius  and  soleus  muscles,  if  made  of  sufficient  tension, 
will  elevate  the  heel  and  restore  the  foot 
to  its  normal  position.  There  are,  how- 
ever, various  instruments  for  the  correc- 
tion of  this  deformity,  the  surgeon  modi- 
fying the  shoe  as  may  be  required  to  suit 
each  case.  In  addition  to  the  mechani- 
cal appliances,  the  after-treatment,  by 
electricity,  massage,  etc.,  should  be  car- 


FiG.  713.— Sayre's  shoe  for  talipes  ealcaneu3. 
(After  Say  re.  J 

ried  out  as  in  other  forms  of  club-foot 
where  atrophy  of  the  muscles  and  loss  of 
power  exist. 

Talipes  Varus  and  Equino-Yarus. — 
These  deformities  consist  of  an  inward 
rotation  of  the  foot,  and  are  the  most 
common  forms  of  talipes  (Figs.  714-717). 
The  majority  of  cases  are  those  in  which 
spastic  contraction  of  the  sural  muscles 
also  occurs  (equino-varus).  Talipes  varus  and  equino-varus  are  more 
often  congenital,  but  are  frequently  acquired,  one  or  both  feet  being  in- 
volved.    The  degree  of  deformity  varies  from  slight  inversion  of  the  foot 


Fig.  714. — Talipes  cquino-vaius  in  an  adult. 
(After  Climchill  ) 


TALIPES  VARUS  AND  EQUIXO-YAEUS. 


815 


to  tlie  most  exaggerated  form  in  which  the  sole  looks  upward,  while  in 
the  act  of  waDdng  the  dorsum  rests  upon  the  gTound. 

The  changes  which  the  structures  of  the  foot  undergo  are  shortening 
of  the  plantar  fascia  and  the  internal  lateral  ligaments,  together  with 


Fig      Id  Fig.  716.  EiG.  717. 

Three  grades  of  talipes  varus.    (After  Churchill.) 

a  contractui'ed  condition  of  the  tibialis  anticus  and  posticus  muscles. 
This  deformity,  therefore,  places  those  muscles  and  ligaments  upon  the 
stretch  which  are  situated  upon  the  outer  aspect  of  the  leg,  and  re- 
sults from  complete  or  partial  paralysis  of  the  peronei  muscles.  The 
displacement  of  the  bones  of  the  tarsus  will  correspond  to  the  extent 
of  the  deformity ;  the  astragalus  being  tilted  downward,  the  scaphoid 
is  displaced  inward  and  downward  by  the  action  of  the  tibialis  jDOsti- 
cus,  the  tubercle  on  this  bone  becoming  very  prominent ;  there  is  in 
addition  marked  rotation  at  the  astragalo-scaphoid  and  calcaneo-cuboid 
junctions,  the  displacement  being  especially  marked  in  this  last-named 
articulation. 

When  the  deformity  exists  at  bii'th,  if  not  corrected  early,  the  bones 
will  become  ossified,  and  the  deformity  permanent.  In  these  cases  tar- 
sotomy and  exsection  are  the  only  means  of  bringing  the  foot  into  its 
normal  position. 

The  treatment  of  talipes  equino-varus  in  the  infant  consists  in  the 
application  of  small  rubber  bands  or  pieces  of  tubing,  which  will  make 
constant  and  gradual  traction  in  the  line  of  the  weakened  or  paralyzed 
muscles.     This  {BarioeW  s)  method  is  as  follows  : 

Cut  a  piece  of  strong  adhesive  plaster  into  the  shape  of  a  fan,  which 
is  split  into  four  or  five  strips  converging  toward  the  apex  of  the  fan 
(Fig.  718).  "The  apex  of  the  triangle  is  passed  through  a  \vire  looj)  with 
a  ring  in  the  toj)  (Figs.  718,  719),  brought  back  upon  itself,  and  secured 
by  sewing.  The  plaster  is  firmly  secured  to  the  foot  in  such  a  manner 
that  the  wire  eye  shall  be  at  a  point  where  we  wish  to  imitate  the  inser- 
tion of  the  muscle,  and  that  it  shall  draw  evenly  on  all  parts  of  the  foot 
when  the  traction  is  applied.  Secure  this  by  other  adhesive  straps  and 
a  smoothly  adjusted  roller. 


816 


A  TEXT-BOOK  ON  SUKGERY. 


"The  artificial  origin  of  the  muscle  is  made  as  follows  :  Cut  a  strip  of 
tin  or  zinc  plate,  in  length  about  two  thirds  that  of  the  tibia,  and  in 
width  one  quarter  the  circumference  of  the  limb  (Fig.  720).  This  is 
shaped  to  fit  the  limb  as  well  as  can  be  done  conveniently.     About  an 


Fig.  719.— (After  Sayre.) 


Fig.  718.— (After  Sayre.) 


Fio.  720.— (After  Sayre.) 


inch  from  the  upper  end  fasten  an  eye  of  wire.  Cai-e  should  be  taken 
not  to  have  this  too  large,  as  it  would  not  confine  the  rubber  to  a  fixed 
point.  The  tin  is  secured  upon  the  limb  in  the  following  manner  :  From 
stout  (mole-skin)  plaster  cut  two  strips  long  enough  to  encircle  the  Umb, 
and  in  the  middle  of  each  make  two  slits  just  large  enough  to  admit  the 


Fig.  721.— (From  Barwell.) 


Fig.  722.— (From  Barwell.) 


tin,  which  will  prevent  any  lateral  motion ;  then  cut  a  strip  of  plaster, 
rather  more  than  twice  as  long  as  the  tin,  and  a  little  wider :  apply  this 
smoothly  to  the  side  of  the  leg  on  which  the  traction  is  to  be  made, 
beginning  as  high  up  as  the  tuberosity  of  the  tibia.    Lay  upon  it  the  tin, 


TALIPES    VARUS   AND   EQUINO-YARFS.  817 

placing  tlie  upper  end  level  with  that  of  the  plaster  (Pig.  721).  Secure 
this  by  passing  the  two  strips  above  mentioned  around  the  limb  (Fig. 
722),  then  turn  the  vertical  strijD  of  plaster  upward  upon  the  tin.  A  slit 
should  be  made  in  the  plaster  where  it  passes  over  the  eye,  in  order  that 
the  latter  may  protrude.  The  roller  should  then  be  continued 
smoothly  up  the  limb  to  the  top  of  the  tin.    The  plaster  is  again  S) 

reversed  and  brought  down  over  the  bandage,  another  slit  being  q 

made  for  the  eye,  and  the  whole  secured  by  a  few  turns  of  the      fig.  723. 
roller.     A   small   chain,  a  few  inches  in  length,  containing  a 
dozen  or  twenty  links  for  graduating  the  adjustment,  is  then         Q^ 
secured  to  the  eye  in  the  tin. 

"Into either  end  of  a  piece  of  ordinary  India-rubber  tubing, 
about  one  quarter  of  an  inch  in  diameter  and  two  to  six  inches 
in  length,  hooks  of  the  pattern  shown  in  Fig.  723  are  fastened 
by  a  wire  oj-  other  strong  ligature.  One  hook  (Fig.  722)  is  fast- 
ened to  the  wire  loop  on  the  plaster  on  the  foot,  and  the  other  ^ 
to  the  chain  above  mentioned,  the  various  links  making  the  fig.  724. 
necessary  changes  in  the  adjustment. 

''The  dressing,  when  complete,  is  shown  in  Fig.  722."     (Sayre.) 
A  roller  should  now  be  carefully  and  smoothly  applied  over  the  plas- 
ter and  between  the  leg  and  the  artificial  muscles. 

When  the  muscles  can  not  be  obtained,  and  in  mild  cases,  in  which 
the  foot  may  be  brought  readily  into  position,  a  correction  may  be  effected 
by  means  of  one  or  more  strips  of  adhesive  plaster  as  follows  :  One  end  of 
the  strip  is  laid  upon  the  dorsum  of  the  foot,  near  the  bases  of  the  third 
and  fourth  toes,  whence  it  is  carried  in  a  slightly  sjMral  direction  to  the 
inner  border  of  the  sole,  and  across  the  sole  to  the  outer  margin  of  the 
foot.  As  the  foot  is  now  brought  into  a  normal  position  by  the  hand  of 
the  operator,  the  strip  of  plaster  is  laid  along  the  outer  and  anterior 
aspect  of  the  leg  and  thigh,  and  firmly  secured  by  encircling  strips  of  the 
same  material.     A  bandage  over  all  will  hold  the  dressing  in  position. 

When  the  patient  is  able  to  walk,  the  club-foot  shoe 
(Fig.  710)  will  give  the  greatest  satisfaction.     The  rub- 
ber muscles  shoiild  be  ajDplied  and  regulated  in  such  a 
way  that  they  will  imitate  as  nearly  as  possible  the  nor- 
mal action  of  the  muscles  they  are  intended  to  assist. 
A  less  expensive  instrument,  one   which   yields  good 
residts  in  the  milder  forms  of  talipes  equino-varus,  and 
which  may  be  readily  made  by  any  ordinary  worker  in 
iron,  is  shown  in  Fig.  725.     It  consists  of  a  sole-piece  of 
sheet-iron,  which  is  riveted  to  a  heel-piece  of  the  same 
material,  and  is  roomy  enough  to  hold  the  heel  of  the 
patient  without  chafing.     It  should  be  nicely  padded, 
Fig.  r25.-iion  shoe     to  prevent  the  danger  of  excoriations.     To  this  heel- 
^'d  eq^o-^rill!     piece  is  attached,  by  a  hinge-joint  with  limited  forward 
and  backward  motion,  an  iron  bar  which  extends  to  the 
padded  iron  collar  around  the  leg,  near  the  knee.     The  foot  of  the  pa- 
tient is  secured  to  the  sole-piece  by  adhesive  plaster,  with  the  aid  of  the 

52 


818 


A  TEXT-BOOK   ON  SURGERY. 


instep-strap  shown  in  Fig.  726,  and  a  flannel  roller  carried 
the  perpendicular  bar  is  now  carried  parallel  with  the  leg 
this  position  by  buckling 
the  collar  around  the  leg  at 
the  knee,  the  foot  is  turned 
outward  and  held  in  its 
normal  position.  An  ordi- 
nary lacing-shoe  should  be 
worn  over  the  brace. 


over 
,  and 


all.     As 
held  in 


Fig.  727. — Eeevos's  universal  shoe,  as  it  is  being  applied  in 
tlie  treatment  of  talipes  equino-varus.     (After  Eeeves.) 


Fig.  726.— Iron  shoe  for  talipes  varas  and 
equino-varus  in  position.  The  adlie- 
sive  strips  and  bandage  have  been 
omitted  in  the  cut. 

An  apparatus,  the  mech- 
anism of  which  is  some- 
what similar  to  this,  is  high- 
ly recommended  by  Mr. 
Reeves,  and  is  shown  in 
Fig.  727. 

The  modification  of  Scar- 
pa's shoe  (Fig.  728)  possess- 
es some  advantages  over  the 

iron  shoe  above  described,  and  should  be  preferred  to  it  when  it  can 
be  obtained. 

Tenotomy  and  fasciotomy  will  be  found  necessary  in  a  large  propor- 
tion of  cases  of  talipes  equino-varus,  and,  when  not  essential  to  ultimate 
success,  it  will  greatly  expedite  the  permanent  restoration  of  the  mem- 
ber to  its  normal  position.  The  api:)lication  of  Esmarch's  bandage  from 
the  toes  to  above  the  knee,  though  not  essential,  renders  the  operative 
procedure  more  rapid  and  easy  of  execution.  The  tendo  Achillis  is 
divided  as  heretofore  directed.  In  addition,  the  tibialis  anticus  and  the 
tibialis  jjosticus  will,  as  a  rule,  require  to  be  divided.  The  tendon  of  the 
tibialis  anticus  should  be  cut  subcutaneously  about  one  inch  above  its 
insertion  into  the  internal  cuneiform  bone  by  introducing  the  tenotome 
beneath  it  from  the  middle  line  of  the  foot.  It  can  be  made  prominent 
by  forcible  eversion  of  the  foot.     Division  of  the  tendon  of  the  tibialis 


Fig.  728. — Modified  Scarpa's  shoe  for  talipes  varus  and  equino- 
varus.     (After  Eeeves.) 


TALIPES   VARUS   AXD   EQUIXO-VARUS.  819 

posticus  is  best  effected  by  an  incision  laarallel  -nitli  the  inner  border  of 
the  tibia  jnst  above  the  internal  malleolus,  where  it  lies  in  close  relation 
to  this  surface  of  the  bone.  As  soon  as  it  is  exposed,  an  aneurism-needle 
should  be  passed  beneath  it,  vrhen  it  can  be  draT\Ti  out  through  the  wound 
and  divided  with  the  scissors.  Subcutaneous  section  of  this  tendon  is 
a  very  difBcult  and  uncertain  procedure,  while  no  mistake  is  possible 
through  an  open  wound.  If  careful  antisepsis  is  practiced,  and  if  the 
wound  is  at  once  closed  with  catgut  sutures,  no  suppuration  can  occur. 
The  i^lantar  fascia  should  be  divided  by  introducing  the  tenotome  flat- 
wise under  the  fascia  from  the  inner  border  of  the  foot,  turning  the  edge 
outward,  and  cutting  the  fascia  as  it  is  made  tense.  Several  lines  of 
section  through  this  fascia  may  be  made  when  necessary.  Bits  of  adhe- 
sive plaster  should  be  placed  over  each  puncture. 

Tarsotomy. — In  exaggerated  and  chronic  cases  of  congenital  talipes 
equino- varus,  a  wedge-shaped  exsection  of  a  portion  of  the  tarsus  will 
at  times  permit  a  restoration  of  the  foot  to  its  normal  position,  and  serve 
to  restore  in  great  part  the  usefulness  of  the  member.  In  two  recent 
cases  in  which  I  performed  this  operation,  the  most  gratifying  results 
were  obtained.  In  each  case  the  patient  walked  with  the  dorsum  of  the 
foot  on  the  floor,  and,  in  one  instance,  the  toes  pointed  directly  back- 
ward. 

After  Esmarch's  bandage  has  been  applied,  a  free  incision  is  made 
along  the  fibular  side  of  the  foot,  extending  from  below  the  external 
malleolus  to  the  tarso -metatarsal  junction.  AH  the  tissues  should  be 
lifted  from  the  bones  by  the  periosteal  elevator,  and  the  wedge-shaped 
section  of  the  tarsus  removed  by  the  gouge  or  chisel.  The  anterior  por- 
tion of  the  astragalus  will  require  to  be  removed,  and  as  much  of  the 
tarsus  should  be  exsected  as  is  needed  to  permit  the  restoration  of  the 
foot  to  the  natural  position  ;  for  it  is  not  only  necessary  to  evert  the 
foot,  but  to  make  at  the  same  time  a  marked  rotation  of  that  part  of 
the  member  anterior  to  the  line  of  section.  The  tendo  AchUlis  should 
now  be  divided,  and,  as  soon  as  the  proper  position  is  obtained,  the 
wound  should  be  irrigated  with  sublimate  solution,  the  incision  closed 
and  covered  with  iodoformized  gauze,  and  a  light  sublimate  dressing 
and  compression-bandage  appUed  tight  enough  to  arrest  all  oozing.  A 
plaster-of-Paris  dressing  is  now  put  on,  and  the  foot  held  in  position 
until  this  hardens.  This  last  procedure  can  be  facilitated  by  adjusting 
two  strips  of  adhesive  plaster,  one  of  which  will  serve  to  hold  the  foot 
at  a  right  angle  to  the  axis  of  the  leg,  and  the  other  to  keep  it  rotated 
outward  while  the  plaster  is  being  applied  and  is  hardening.  The  dress- 
ing may  be  removed  not  earlier  than  the  fifteenth  day,  and  should  not 
be  disturbed  for  a  month  unless  from  soiling  or  smelling  it  is  necessi- 
tated. 

Talipes  Valgus.— In  this  deformity  the  normal  arch  of  the  foot  is 
lost,  and  the  foot  is  everted  (Figs.  729,  730,  731,  782).  The  contracted 
muscles  are  the  peroneus  longus  and  brevis,  while  the  paralysis,  as  a 
rule,  affects  the  tibialis  posticus,  anticus,  and  flexor  muscles.  When  the 
tarsal  arch  gives  way,  the  plantar  fascia,  calcaneo-cuboid  ligaments,  and 


820 


A  TEXT-BOOK  ON   SURGERY. 


short  flexors  become  stretched,  and  the  tibialis  anticus  is  elongated.  The 
yielding  of  these  muscles  may  be  due  to  paralysis,  or  to  strain  from  the 
habit  of  carrying  heavy  weights. 


j^i_,„V 


Fig.  729. — Congenital  talipes  valgus. 
(After  Churchill.) 


Fig.  T30. — Acquired  talipes  valgus. 
(After  Churchill.) 


Fig.  731. — Inner  view  of  a  severe  valgus  of  the  right  foot. 
(After  Eeeves.)  1,  Inner  malleolus.  2,  Inner  surface 
of  head  of  astragalus.    3,  Tubercle  of  scaphoid. 


Treatment. — In  talipes  val- 
gus in  an  infant  the  eversion 
may  be  corrected  by  means  of 
the  adhesive  strips  applied  as 
in  the  treatment  of  varus.  The 
dii'ection  of  traction  is  of 
course  opposite.  The  artificial 
muscles,  after  the  method  of 
Barwell,  are  also  as  applicable 
here  as  in  varus.  The  iron 
shoe  (Fig.  725),  made  with  the 
bar  to  come  upon  the  inner 
side  of  the  leg,  is  as  service- 
able in  mild  cases  of  valgus  as 
in  varus  or  equino-varus.  This 
apparatus  is  always  worn  in- 
side of  an  ordinary  shoe.  ISTy- 
rop's  boot  (Fig.  733)  is  highly 
recommended  by  Mr.  Reeves. 
It  consists  of  a  stiff-soled  lacing- 
shoe,  with  a  leg-collar  and  iron 
or  steel  bar  attached  to  the 
outer  side  of  the  shoe,  with  a 
lateral  hinge  opposite  the  out- 
er malleolus.  To  the  inner  side  of  the  sole,  near  the  heel,  is  attached  a 
strong  piece  of  elastic  webbing,  by  which  inversion  of  the  foot  is  effected 
by  buckling  the  strap  to  the  collar  near  the  knee. 


Fig.  732. — Inner  view  of  tie  bones  of  a  severe  valgus. 
(After  Eeeves. )  1,  Tubercle  of  scaphoid.  2,  Astrag- 
alus. 3,  Os  calcis.  4,  Internal  cuneiform  bone.  5, 
First  metatarsal. 


TALIPES  CAVUS.— TALIPES  PLANUS.  821 

When  tenotomy  of  the  peronei  muscles  is  indicated,  they  should  be 
divided  subcutaneously  fi'om  three  quarters  to  one  and  a  half  inch  (owing 
to  the  age  of  the  patient)  above  the  external  malleolus.     Cuneiform  tar- 
sotomy may  be  applied  to  the  correction  of  this  de- 
formity in  exaggerated  cases  in  adults.     When  the 
bones  are  thoroughly  ossified  it  will  be  impossible  to 
change  the  shape  of  these  organs  and  restore  the 
normal  shape  of  the  part  by  any  mechanical  appa- 
ratus, no  matter  how  persistent  in  its  use.     The  in- 
cision is  made  along  the  inner  side  of  the  foot,  and 
the  apex  of  the  conical  section  must  be  at  the  outer 
border  of  the  tarsus.     The  details  of  the  operation 
and  the  after-treatment  are  practically  the  same  as 
given  for  equino-varus. 

Talipes  Cavus. — Hollow-foot  is  almost  always  an 
acquired  deformity,  although  it  may  be  congenital. 
It  occurs  with  talipes  calcaneus,  equinus,  and,  in  a 
mild  degree,  may  complicate  varus  and  equino-varus.  (After^Eeeves.™ 

In  this  deformity  the  antero-posterior  arch  of  the 
foot  is  exaggerated,  the  plantar  fascia  and  the  muscles  of  the  plantar 
region   which   have   their   origin  behind   the   medio-tarsal    joint,    and 

are    inserted    anterior  to   this  articula- 

,^  "'"y>,       tion,  are  shortened.     The  plantar  fascia 

and   the   calcaneo- cuboid   ligaments  are 

also  shortened.     The  sole  of    the  foot 

.,  no  longer  rests  upon  the  floor,  as  in  the 

Fig.  V34.-Sliowma  tlie  surface  of  the  sole       normal    Condition    (Fig.  734),    but    touch- 
foot  ^(Aft'er"iay  re!)''  *'°°''  '"'•""'■"'^     es  only  at  the  heel  and  along  the  meta- 

tarso-phalangeal  line. 
Any  inflammatory  process  of  the  plantar  region  may  induce  contrac- 
tion of  the  fascia  or  ligaments  ;  or  spastic  contraction  of  the  muscles  of 
this  region  from  local  or  remote  causes  may  produce  this  deformity.  Com- 
mencing before  the  bones  are  softened,  the  distortion  of  the  foot  is  apt 
to  become  permanent  unless  exsection  or  crushing  is  performed.  Of 
these  two  procedures,  tarsoclasis  is  the  most  readily  accomplished; 
but,  when  the  tarsoclast  can  not  be  had,  section  through  the  tarsus, 
with  a  thorough  division  of  the  plantar  fascia,  will  be  Justifiable.  For- 
tunately, few  instances  will  occur  where  such  harsh  procedures  will  be 
called  for. 

In  recent  cases  the  deformity  may  be  relieved  by  wearing  a  plain  shoe 
with  a  low,  broad  heel  and  straight,  thick  sole.  The  plantar  fascia 
should  be  divided  in  all  cases  which  do  not  readily  yield  to  mechanical 
treatment. 

Talipes  Planus .—Flat-ioot  has  been  partially  considered  with  talipes 
valgus,  with  which  condition  it  is  almost  always  associated.  The  antero- 
posterior arch  of  the  foot  is  more  or  less  obliterated,  and  in  severe  cases 
the  anterior  portion  of  the  sole  spreads  out  or  widens  in  its  transverse 
diameter  (Fig.  735). 


822 


A  TEXT-BOOK  ON   SURGERY. 


Fio.  705. — Cast  of  the  right  foot  in  a 
case  of  talipes  planus,  at  the  Poly- 
clinic. 


Tlie  plantar  fascia  and  calcaneo-cuboid  ligaments  are  stretched,  the 
internal  lateral  ligaments  of  the  ankle-joint  are  generally  involved,  while 
the  tibialis  anticus  and  the  antero-posterior  muscles  of  the  plantar  as- 
pect of  the  foot  are  elongated.  The  princi- 
pal cause  of  this  deformity  is  the  habitual 
carrying  of  heavy  burdens,  or  pressure  of 
the  superincumbent  weight  of  the  body  upon 
the  arch  of  the  foot,  together  with  lack  of 
tonicity  in  the  muscles,  and  of  strength  in 
the  ligaments  and  fascia. 

Treatment. — It    is    exceedingly    difficult 

and  in  the  majority  of  cases  impossible  to 

correct  this  deformity.     The  best  method  is  to  support  the  arch  of  the 

foot  by  a  comfortable  adjustment  of  ijressure  by  inserting  a  piece  of  felt 

in  the  sole  of  the  shoe,  just  beneath  the  arch. 

The  deformities  of  the  toes  are  congenital  and  acquired.  The  con- 
genital deviations  from  the  normal  are  the  presence  of  one  or  more  su- 
pernumerary toes  {polydactylus),  or  the  absence  of  one  or  more  of  these 
members  {syndactylus). 

In  polydactylus  the  most  frequent  supernumerary  toe  is  one  connected 
with  the  great-toe,  attached  usually  on  its  inner  or  tibial  aspect,  near  the 
junction  of  the  metatarsal  bone  and  phalanx.  In  a  rare  case  of  this  de- 
formity, reported  by  Prof.  Sayre,  there  were  eight  toes  on  the  right  and 
ten  on  the  left  foot. 

Treatment. — All  minor  deformities  the  removal  of  which  does  not 
endanger  the  life  of  the  individual,  or  diminish  the  usefulness  of  the 
member  affected,  demand  amputation  within  the  first  year  or  two  of  life, 
before  the  patient  is  old  enough  to  become  conscious  of  possessing  a  de- 
formity. 

Syndactylus  is  a  term  applied  not  only  to  the  partial  or  entire  ab- 
sence of  one  or  more  fingers,  but  also  to  the  condition  known  as  congen- 
ital web-toe.  ' 

Web-toes  may  be  treated  in  the  same  way  as 
web-fingers.  If  neglected  until  the  child  is  old 
enough  to  become  accustomed  to  the  deformity, 
operation  is  of  doubtful  propriety. 

When  one  or  more  toes  are  missing,  as  in  Fig. 
736,  even  when  the  deformity  is  offensive  to  the 
sight,  the  question  of  operative  interference  (except 
for  relief  from  pain)  should  depend  upon  the  de- 
gree of  usefulness  enjoyed  by  the  deformed  mem- 
ber. An  important  principle  in  the  surgery  of  the 
foot  is  to  save  every  particle  of  surface  for  the  sup- 
port of  the  body.  This  conclusion  gains  additional  force  in  the  ability 
to  conceal  the  deformity  by  a  properly  constructed  shoe. 

The  acquired  deformities  of  the  toes  result  in  almost  all  cases  from 
improperly  adjusted  shoes.  The  displacement  may  be  in  all  directions, 
although  those  of  the  great  and  little  toes  are  usually  toward  the  median 


Fig.  738.  —  Syndactylus  in 
the  right  foot  of  a  boy. 
(After  Reeves.) 


HALLUX   VALGUS. 


823 


line  of  the  foot.     The  middle  toes  may  be  flexed  in  one  Joint,  extended 
in  another,  or  crossed  over  each  other. 

Hallux  valgus,  or  displacement  of  the  great-toe  toward  the  fibular  or 
outer  side  of  the  foot,  is  a  common  deformity  (Fig.  738).  In  exagger- 
ated instances  mechanical  or  surgical  interference  is  demanded.  Hallux 
valgus  is  caused  chiefly  by  shoes  which  are  pointed  at  the  tip  and  are  too 
short  for  the  foot.  It  may  also  occur  with  club-foot,  and  generally  with 
talipes  varus  and  planus.  The  action  of  the  muscles  inserted  into  the 
base  of  the  great-toe  must  not  be  altogether  overlooked  in  the  getiology 
of  this  deformity.  Of  the  five  muscles  which  arise  from  the  tarsus  and 
metatarsus  and  are  inserted  into  this  toe,  all  but  one  tend  to  carry  it  to- 
ward the  fibular  side  of  the  foot. 

In  being  displaced,  the  great- toe  usually  is  carried  above  the  second 
or  third  toe,  occasionally  beneath  it.  The  phalanx  is  more  or  less  com- 
pletely dislocated  from  the  original  articular  surface  of  the  metatarsal 
bone,  being  twisted  around  to  its  outer  lateral  aspect.  The  cartilage  of 
the  old  portion  disappears,  and  a  new  Joint-surface  is  developed  on  the 
external  aspect  of  the  metatarsal  bone.  From  pressure,  a  callosity  of 
varying  thickness  develops  over  the  tip  of  the  metacarpus,  adding  greatly 
to  the  appearance  of  deformity. 

Treatment. — Mild  cases  of  hallux  valgus  may  be  cured  by  elastic  ten- 
sion steadily  applied,  as  follows :  A  soft  kid  or  chamois-skin  cover  is 
made  for  the  afl'ected  toe,  and  to  the  end  of 
this  a  piece  of  thin  elastic  webbing  is  at- 
tached. To  the  webbing  a  strip  of  adhesive 
plaster  is  stitched,  and  this  is  carried  around 
the  heel  and  is  made  to  adhere  along  the 


Fig.  73T. — Sayre's  method  of  treating 
hallux  valgus.     (After  Sayre.) 


Fig.  738.— Hallux  valgus.     (From  a 
patient  at  Mount  Sinai  Hospital.) 


Fig.  739.— The  same 
after  operation. 


outer  side  of  the  foot  in  such  a  way  that  the  webbing  is  made  to  draw 
the  toe  outward  (Fig.  737). 

In  severe  cases,  operative  interference  can  alone  restore  the  toe  to  its 
normal  position.  The  operation  consists  in  an  incision  made  along  the 
inner  side  of  the  foot,  the  center  of  which  is  over  the  angular  projection 
at  the  end  of  the  metatarsal  bone.  The  callosity  should  be  removed,  the 
Joint  opened,  a  wedge-shaped  segment  removed  from  the  end  of  the 
metatarsal  bone  and  the  phalanx.  Enough  should  be  removed  with  the 
exsector  or  metacarpal  saw  to  permit  the  bones  to  be  brought  into  proper 


824  A  TEXT-BOOK   ON  SURGERY. 

position,  where  they  should  be  held  by  a  silver-wire  suture  passed  w^ell 
into  the  bone  a  half -inch  from  the  cut  surface ;  or  the  bones  may  be  held 
in  apposition  by  transfixion  with  small  steel  drills.  Fig.  738  is  from  a 
cast  taken  from  a  patient  at  Mount  Sinai  Hospital  upon  whom  I  did  this 
operation  in  both  feet.     The  degree  of  correction  is  shown  in  Fig.  739. 

This  operation  is  preferable  to  that  of  osteotomy  of  the  first  metatar- 
sal bone  just  behind  the  articulation,  for  the  reason  that  the  callosity 
and  projection  opposite  the  joint  can  only  be  removed  by  excision. 

Hallux  varus,  or  pigeon-toe,  is  a  much  rarer  deformity,  and  occurs 
usually  as  a  result  of  cicatricial  contractions  or  from  spastic  action  of 
the  abductor-pollicis  muscle.  The  treatment  consists  in  adjusting  a  well- 
made  shoe  which  will  push  the  toe  into  its  proper  position.  Division 
of  any  cicatricial  tissue  or  the  tendon  of  the  abductor  muscle  may  be 
necessary. 

Displacement  of  the  little  toe  is  usually  inward  and  beneath  the 
fourth.  The  same  treatment  may  be  applied  in  this  deformity  as  given 
for  hallux  valgus. 

Flexion  of  the  toes  may  be  complete  when  there  is  paralysis  of  the 
extensor  muscles.  The  most  usual  form  is  that  in  which  the  first  phalanx 
is  tilted  upward,  that  is,  seemingly  extended,  while  the  distal  phalanx  is 
drawn  downward,  so  that  the  nail  is  to  the  front,  and  the  tip  of  the  toes 
rests  upon  the  ground.     This  condition  is  also  known  as  Jiammer-toes. 

The  cause  is  chiefly  one  of  improper  shoeing,  by  which  the  toes  are 
not  allowed  to  be  fully  extended,  and,  being  held  in  this  cramjped  position 
by  the  shoe,  the  muscles  and  fascise  become  pennanently  shortened.  The 
plantar  fascia  is  iisually  involved  in  chronic  cases.  The  extensor  mus- 
cles become  shortened  as  well  as  the  flexors,  which  are,  however,  the 
principal  agents  in  producing  the  deformity. 

Extension  of  the  toes  beyond  the  normal  line  is  a  rare  condition.  It 
could  only  be  caused  by  paralysis  of  the  flexors. 

Treatment. — In  mild  cases  of  incipient  hammer-toes  a  cure  may  be 
effected  by  wearing  a  shoe  long  enough  to  allow  these  members  to  be 
extended.  In  more  chronic  and  obstinate  cases, 
a  metal  sole  should  be  adjusted  so  that  an  ordi- 
nary shoe  can  be  worn  over  it.  Just  beneath  the 
middle  of  the  toes  is  a  series  of  perforations  in 
the  sole,  through  which  loops  are  passed.  The 
toes  are  straightened  by  traction  on  the  loops, 
^     ^,„     ,  ^    ^  which  are  tied  below  (Fig.  740).     In  some  in- 

iiG.  740. — Apparatus  lor  nam-  i>      n      \  n 

mer-toes.   (Alter  Eeeves.)        stauces  tenotomy  oi  the  loug  flexor  and  extensor 

muscles  and  of  the  plantar  fascia  is  essential. 

The  tendons  of  the  extensor  digitorum  should  be  subcutaneously  divided 

just  over  the  bases  of  the  toes  ;  the  flexor  tendons  near  the  middle  of  the 

plantar  surface  of  these  members. 

Bunions  are  callosities  resulting  from  intermittent  pressure  upon  cer- 
taia  portions  of  the  foot. 

Corns  are  both  hard  and  soft.  A  hard  corn  differs  from  a  bunion 
only  in  size.     Soft  corns  are  small  ulcers  situated  between  the  toes  or  in 


IX-GROWrMG  NAIL.  825 

the  fissures  on  tlie  imder  surface.  They  are  cau-sed  by  fi-iction  of  opposing 
surfaces  and  moisture. 

Bunions  and  hard  corns  are  to  be  treated  by  relieving  the  unnatural 
pressure  which  caused  them.  Comfortably  fitting,  yet  not  necessarily 
loose  shoes,  of  soft  leather,  should  be  worn.  Pieces  of  Canton  flannel, 
cut  into  rings  and  laid  upon  each  other  so  that  the  pressure  vnM  be  dis- 
tributed to  the  surfaces  near  the  corn,  -nill  be  advisable,  in  simple  cases, 
even  when  loose  shoes  are  adopted.  A  small  tuft  of  cotton  dipped  in 
vaseline  will  aid  in  softening  the  hard  covering.  Soft  corns  may  be 
readily  cured  by  inserting  pellets  of  absorbent  cotton  moistened  with 
borax  dissolved  in  glycerine,  and  api)lied  so  as  to  protect  the  raw  sur- 
faces and  prevent  friction. 

In-growing  nail  is  one  of  the  commonest  affections  of  the  feet,  and  is 
almost  always  met  with  in  the  great  toe.  The  palliative  treatment  is  to 
cut  away  portions  of  the  nail  near  the  inflamed  surface  and  protect  this 
by  a  small  jDellet  of  lint  moistened  in  the  borax  and  glycerine  mixture. 
The  employment  of  cocaine,  however,  enables  the  surgeon  to  remove  the 
offending  nail  without  a  particle  of  pain,  and  in  this  way  a  permanent 
and  radical  cure  is  readily  effected.  I  have  performed  this  operation 
repeatedly  after  the  following  method :  The  foot  and  toes  should  be 
cleansed  and  thoroughly  disinfected.  An  elastic  ligature  should  be 
thrown  around  the  toe,  as  close  to  the  metatarsal  jimction  as  possible. 
The  anaesthesia  is  effected  by  introducing  the  hypodennic  needle  of  the 
cocaine- syringe  beneath  the  skin  on  the  dorsum  of  the  toe,  half  an  inch 
behind  the  nearest  surface  of  the  nail — i.  e.,  just  about  the  posterior  bor- 
der of  the  matrix.  Three  or  four  drops  of  a  4-j)er-cent  solution  are  forced 
out  here  and  the  needle  pushed  under  the  skin,  to  right^nd  left,  until 
from  fifteen  to  twenty  minims  have  been  injected  across  the  toe  and  on 
either  side  of  the  nail  toward  the  tip  of  the  toe.  The  line  of  this  injec- 
tion is  in  the  shape  of  a  horseshoe.  The  needle  should  now  be  removed, 
and  reinserted  through  the  anaesthetized  skin,  and  carried  thence  subcu- 
taneously  until  the  anaesthesia  is  complete  at  all  points  around  the  nail. 
Forty  minims  of  a  4-per-cent  solution  may  be  employed,  although  half 
this  quantity  will  generally  suffice.  In  from  tkree  to  five  minutes  in- 
sensibility is  perfect.  An  incision  is  first  made  from  the  middle  of  the 
posterior  margin  of  the  nail  directly  backward  for  half  an  inch.  A  sec- 
ond incision  across  the  tojD  of  the  toe,  extending  as  low  down  as  the  most 
inferior  portion  of  the  nail,  on  either  side,  uniting  with  the  central  end 
of  the  perpendicular  cut,  gives  the  entire  wound  a  T-shape.  The  two 
quadrilateral  flajjs  of  skin  are  now  dissected  up,  turned  one  to  the  right 
and  one  to  the  left  side,  and  held  away  by  the  weight  of  an  artery -forceps 
or  by  retractors.  The  nail  should  next  be  split  from  before  backward  in 
the  middle  line,  the  incision  extending  through  the  matrix  as  far  back  as 
the  transverse  incision  through  the  skin.  Both  halves  and  the  matrix 
should  be  thoroughly  extirpated,  all  granulation- tissue  scraped  out,  and 
the  foot  dipped  into  a  basin  of  warm  sublimate  solution,  l-to-2000.  At 
this  junctnre  the  elastic  tourniquet  should  be  removed,  and  the  wound 
allowed  to  bleed  for  a  minute.     By  this  means  the  excess  of  cocaine  solu- 


826 


A   TEXT-BOOK   ON   SURGERY. 


tion  is  washed  out  of  the  tissues.  The  ligature  should  then  be  reapplied. 
The  flaps  are  now  brought  into  position,  the  space  formerly  occupied  by 
the  horny  part  of  the  nail  packed  with  sublimate  gauze,  and  the  entire 
toe  enveloped  in  the  same  material.  A  narrow  bandage  should  be  applied 
firmly  enough  to  hold  the  gauze  in  place,  and  to  exercise  sufficient  com- 
pression to  prevent  bleeding.  Over  this  a  generous  piece  of  protective 
should  be  thrown  and  a  second  bandage  applied.  When,  in  applying 
this  bandage,  the  elastic  ligature  is  reached,  it  should  be  taken  off  and 
the  roller  carried  on  to  the  foot.  A  single  dressing  usually  suffices,  and 
it  need  not  be  removed  for  ten  days  or  two  weeks.  When  the  nail  has 
cut  into  the  soft  parts  only  on  one  side,  a  less  radical  procedure  is  advis- 
able. The  cocaine  is  injected  along  the  line  of  the  in-grown  nail,  and  a 
long  wedge-shaped  strip  of  skin  and  subcutaneous  tissue  removed  with 
the  scalpel.  As  the  wound  heals  by  granulation,  the  soft  parts  are  re- 
tracted below  the  level  of  the  nail. 

Deformities  of  the  Upper  Extremity — Clavicle. — Congenital  absence 
of  portions  of  one  or  both  of  these  bones  may  exist.  No  case  of  complete 
absence  of  the  collar-bone  is  as  yet  on  record.  The  partial  deficiency 
may  occur  on  one  or  both  sides,  and  is  usually  at  the  inner  extremity. 
The  indications  in  treatment  are  to  use  a  figure-of-8  brace  around  the 
shoulders  to  prevent  them  from  being  approximated  in  part  by  the 
actions  of  the  pectoral  muscles. 

Paralysis  of  the  'deltoid  and  serratus  magnus  muscles  imparts  to 
the  shoulder  a  deformed  appearance.     In  deltoid  paresis  the  shoulder 

is  flattened,  and  the 
acromion  process  more 
prominent  and  easily 
recognized.  The  arm 
is  incapable  of  being 
lifted  to  a  right  angle 
vnth  the  spine.  It 
may  be  due  to  inju- 
ry of  the  circumflex 
nerve,  or  to  a  central 
nervous  lesion.  When 
the  serratus  magnus 
is  paralyzed,  the  ver- 
tebral border  of  the 
scapula  is  tilted  out- 
ward in  a  position  of 
unusual  i^rominence. 
Neither  of  these  inju- 
ries is  amenable  to 
surgical  treatment. 
Anchylosis  of-  the 
shoulder  is  more  amenable  to  the  operation  of  exsection  than  to  forci- 
ble breaking  up  of  the  adhesions.  This  last  procedure  may  be  em- 
ployed in  cases  of  partial  anchylosis  in  which  no  inflammatory  process 


—Congenital  fusion  of  tbe  radius  and  ulna. 
(Fiom  a  case  at  the  Polyclinic.) 


ANCHYLOSIS. 


827 


is  going  on.     In  ancTiylosis  of  the  elbow-joint  the  same  treatment  is 
advisable. 

Deformities  of  the  forearm  are  comparatively  rare.  Of  the  congenital 
variety,  occasionally  there  exists  a  fusion  of  the  two  bones.  The  length 
of  the  forearm  is  normal,  as  is  the  motion  at  the  elbow-joint,  but  supi- 
nation and  pronation  are  impossible.  In  the  only  case  I  have  ever  seen, 
from  which  Fig.  741  is  taken,  the  hands  were  in  the  prone  position.  Op- 
erative interference  was  not  indicated  in  this  instance. 


Fig.  742.— Deformity  rfsultiii,'  fiom  bubpei  ■  -      i  .  \  ci'  •  ii  ■  .    he  eiUiiu  ndim  for  ostitis.     (From  a  case 
opeiatv,a  „L  »„  t„„  1'-,!^  „..nic.^ 

Distortions  due  to  rickets  are  at  times  met  with,  and  may  result  from 
the  action  of  the  muscles  upon  the  softened  bones,  or  to  pressure  from 
the  habitual  carrying  of  burdens  in  the  hands.  In  destruction  of  one  of 
the  bones  of  the  forearm  by  ostitis,  or  after  its  removal,  deformity  usually 
results,  the  deviation  of  the  hand  being  toward  the  side  of  the  missing 
bone  (Fig.  742). 

Treatment— In  deformity  after  rickets,  correction  by  osteotomy  is 
justifiable  after  the  disease  is  arrested.  In  the  distortions  due  to  loss  of 
substance  there  is  little  hope  of  relief.    If  the  loss  on  one  side  is  limited. 


828  A  TEXT-BOOK   ON  SURGERY. 

exsection  of  a  portion  of  the  soimcl  bone  and  reunion  of  the  divided  sur- 
faces by  wire  sutures  might  be  entertained. 

Club-Hand. — Distortions  of  the  hand,  not  unlike  those  already  de- 
tailed as  occurring  in  the  foot,  yet  far  less  common,  may  be  met  with. 
The  deformity  may  be  at  the  wrist-joint,  in  the  intercarpal  or  carpo- 
metacarpal articulations,  and  may  be  due  to  failure  of  development  in 
the  bones  of  the  forearm  or  hand,  to  muscular  paralysis,  to  fracture, 
dislocations,  or  cicatricial  contractions. 

In  the  congenital  deiiciencies,  the  radius  is  more  often  wanting,  or 
only  partially  developed,  allowing  the  hand  to  be  carried  toward  the  ra- 
dial side.  The  carpus  is  occasionally  deficient.  Not  infrequently  the 
congenital  cases  are  symmetrical,  and  the  lower  extremities  are  also  in- 
volved. 

The  muscles  are  deficient  in  some  of  these  cases  of  osseous  maKorma- 
tion.  The  usual  condition  in  paralysis  is  that  of  flexion  of  the  carpus 
and  metacarpus  upon  the  forearm. 

This  variety  is  termed  palmar  ;  the  opposite,  dorsal  club  -  hand. 
When  the  displacement  is  lateral  it  is  called  radial  or  ulnar,  as  the  hand 
is  carried  outward  or  inward.  As  in  club-foot,  there  are  compound  forms 
of  club-hand. 

As  to  frequency  in  the  congenital  types,  the  radius  being  chiefly  at 
fault,  the  radial  distortion  is  most  frequent.  When  fi'om  any  cause  the 
equilibrium  between  the  muscles  is  impaired,  the  hand  is  usually  flexed 
uj)on  the  forearm,  and  the  condition  is  known  as  palmar  club-hand. 
With  this  there  may  be  radio-palmar  or  ulno-palmar  deformity. 

Fracture  of  the  radius  (CoUes's),  or  epiphyseal  separation,  may  induce 
a  mild  form  of  radial  club-hand.  Unreduced  dislocations  will,  of  course, 
cause  deformity.  Deformities  due  to  cicatricial  contraction,  as  after 
burns  (Fig.  148),  extensive  phlegmons,  etc.,  are  occasionally  met  with. 

The  treatment  of  all  these  different  varieties  of  club-hand  will  depend 
upon  the  particular  cause.  In  the  worst  form  of  congenital  deformity, 
amputation  at  or  shortly  after  birth  should  be  performed.  Other  and 
milder  cases  may  be  improved  by  mechanical  apparatus  constructed  to 
meet  the  indications. 

In  muscular  paralysis  the  same  general  rules  of  practice  as  laid  down 
in  club-foot  due  to  this  cause  should  be  followed.  Tenotomy  may  be 
necessary.  The  extensors  may  be  subcutaneously  divided  about  the 
middle  of  the  metacarpal  bones.  The  flexors  slightly  above  the  wTist- 
joint.  The  lateral  deformities  also  will  Justify  in  some  cases  division  of 
the  contracting  muscles.  The  rule  to  be  followed  is  to  do  subcutaneous 
tenotomy  when  the  tendon  to  be  divided  is  far  enough  away  from  any 
important  nerve  or  vessel  to  allow  a  perfectly  safe  and  sure  division  of 
the  tendon  ;  if  not,  the  tendons  should  be  exposed  by  incision  under 
strict  antisepsis,  and  each  one  picked  up  on  an  aneurism-needle  and 
divided  in  plain  view. 

The  propriety  of  breaking  up  adhesion  in  anchylosis  with  malposition, 
or  of  resection,  should  be  determined  by  the  condition  of  the  parts  and 
of  the  patient,  and  the  necessities  of  the  case. 


THE  FINGERS  AND  HAND. 


829 


The  Fingers  and  Hand. — Among  the  congenital  deformities  of  the 
fingers  are  polydactylus,  syndactylus,  and  web-finger,  or  fusion  of  two 
or  more  digits.  The  acquired  deformities  are  due  to  contraction  of  the 
palmar  fascia,  of  the  muscles  and  tendons,  to  paralysis  of  certain  mus- 
cles, and  to  osseous  and  articular  lesions,  both  traumatic  and  idiopathic. 

8u2>ernumerary  Finger  {Polydactylus). — The  usual  location  of  one 
extra  finger  is  on  the  radial  side  of  the  thumb  or  ulnar  aspect  of  the 
little  finger,  near  the  metacarpo-phalangeal  junction  (Fig.  743).  It  may 
or  may  not  possess  phalanges  or  cartilages.  If  the  j)halanges  exist,  a 
synovial  cavity  will  be  found  at  the  junction  with  the  metacarpal  bone, 
or  with  the  phalanx  of  the  normal  member. 


Fig.  743. — Supernumerary  digits.     (After  Keeves.) 


Fig.  la. — Doutle  hand.     (After  Eeeves.J 


A  rare  form  of  supernumerary  fingers  is  shown  in  Fig.  744,  in  which 
there  is  practically  a  double  hand.  Amputation  of  the  supernumerary 
members  should  be  made  soon  after  birth. 

In  syndactylus,  all  or  a  portion  of  one  or  more  fingers  may  be  want- 
ing (Fig.  745).    Amputation  of  the  deformed  portion  is  usually  advisable. 

Weh-finger  is  usually  congenital,  although  it  may  be  acquired.  In 
mild  cases,  where  the  union  between  the  contiguous  surfaces  is  slight, 


Fig.  745.— Stunted  and  webbed  haud. 
(After  Keeves.) 


Fig.  746. — Elastic  ligature  passed  through  the  web. 
(After  Fort  and  Noble  Smitlu) 


and  the  web  is  thin,  the  following  method  will  succeed :  A  round  elastic 
ligature  or  cord  is  carried  through  the  web  just  in  front  of  the  metacarpo- 
phalangeal articulation,  and  the  ends  are  turned  back  and  attached  to 
a  band  around  the  wrist  (Fig.  746).     This  is  allowed  to  remain  for  three 


830 


A   TEXT-BOOK   ON   SURGERY. 


or  four  weeks,  until  the  hole  made  by  the  ligature  is  lined  with  epider- 
mis. A  second  puncture  should  now  be  made  about  one  inch  in  front  of 
the  first,  the  ligature  passed  through  this,  and  the  ends  tied.  The  con- 
stant traction  of  the  elastic  gradually  cuts  through  the  web,  yet  so  slowly 
that  the  track  of  the  wound  becomes  covered  with  epidermis.  This  pro- 
cedure should  be  repeated  until  all  the  web  is  divided. 

When  the  fingers  are  solidly  united,  the  method  of  Didot  should  be 
preferred.  An  incision  is  made  down  the  palmar  surface  of  one  finger 
(the  index.  Fig.  747)  and  along  the  dorsal  surface  of  the  adjoining  mem- 
ber (the  middle  finger).  The  flaps  are  dissected  up  so  that  the  one 
removed  from  the  palmar  surface  of  the  index-finger  remains  attached  to 
the  middle  finger,  while  the  posterior  flap  is  attached  along  the  dorsum 
of  the  index-finger.     They  are  then  sutured  in  position  (Fig.  748). 


Fia.  747. — Didot's  method  of  operating  for 
web-fingers.  (After  Fort  and  Ivoble 
Smith.) 


Fig.  748.— Transverse  sections  of  the  webbed 
fingers,  showing  in  tLe  upper  figure  the 
line  of  separation  between  the  two  flaps  ; 
in  the  middle,  the  outline  of  the  sepa- 
rated flaps;  helow,  the  sutures  are  ap- 
plied.    (After  Fort  and  Noble  Smith.) 


In  those  cases  in  which  the  bones  are  only  slightly  united,  the  line  of 
union  may  be  sawed  through.  When  the  bones  are  fused  into  one  solid 
mass,  an  operation  is  not  indicated. 

Chronic  flexion  of  one  or  more  fingers  may  result  from  paralysis  of 
the  extensor  muscles,  spastic  contraction  of  the  flexors,  or  to  contractions 
of  the  palmar  and  digital  fascia.  Paralysis  of  the  extensors  may  be 
temporary  or  permanent.  Lead-poisoning  not  infrequently  leads  to  tem- 
porary impairment  of  the  function  of  this  group  of  muscles. 

In  neglected  cases  of  chronic  extensor  paralysis,  permanent  shorten- 
ing of  the  opposing  muscles,  with  contraction  of  the  palmar  fascia, 
occurs. 

The  indications  in  treatment  are  to  restore,  if  possible  the  functions 
of  the  paralyzed  muscles,  and  to  prevent  deformity  by  the  adjustment 
of  an  apparatus  which  will  keep  the  fingers  extended. 

Contraction  of  the  palmar  fascia,  as  a  result  of  any  inflammatory  pro- 


DrPUTTREN'S   COXTRACTIOX.— SXAP-FIXGER. 


831 


cess,  gives  rise  to  the  most  common  deformity  of  the  fingers.     Penetrat- 
ing wounds  of  the  palm,  or  idiopathic  phlegmon,  are  exceedingly  apt  to 
result  in  fascial  contraction  and  chronic  mal- 
'^^^  position  of  the  fingers. 

I   \  This  process  takes  place  at  times  in  per- 

y-A  sons  of  the  gouty  or  rheumatic  diathesis  with- 

\     \  out  any  marked  symptom  of  local  inflamma- 

^--^  tion.     The  tendons  are  not  afi'ected,  as  a  rule, 


A 


Fig.  749.  —  Dupuytren's  con- 
traction in  tne  fascia  of  the 
palm  and  of  tlae  little  finger. 
(Alter  Xoble  Smith."' 


Fig.  750. — The  same,  in  the  middle  and  ring  fingers,  a.  Contract- 
ed band  of  palmar  fascia,  i,  Flexor  tendons  (not  involved., 
e,  Sheath  of  tendons,  d^  Digital  prolongations  of  palmar  tiis- 
cia.     (Alter  W.  Adams  and  ZS'oble  Smith.) 


in  the  earlier  stages  of  DiipuytreriJs  contraction.  In  old  cases  the  mus- 
cles ai'e  shortened.  The  fascial  contractions  are  well  shown  in  Figs.  749 
and  750. 

Treatment. — In  mild  cases,  taken  early  in  the  commencement  of  the 
affection,  a  cure  may  be  effected  by  repeated  stretching  of  the  fascia  by 
fully  extending  the  fingers  involTed.  The  instrument  shown  in  Fig. 
750  A,  devised  by  Dr.  Battey,  of  Xew  York,  will  be  found  very  useful 
in  such  cases.     In  obstinate  cases  fasciotomv  is  demanded.     Division  of 


the  palmar  fascia  should  be  done  as  follows  :  The  hand  should  be  ren- 
dered thoroughly  aseptic  by  washing  in  sublimate  solution,  and  made 
bloodless  by  Esmarch"s  bandage.  The  hypodermic  injection  of  4-per- 
cent cocaine  solution  renders  the  operation  painless.  The  delicate 
fascia-knife  (li'ig.  59)  should  be  introduced  beneath  the  bands  of  fascia, 
which  can  be  made  prominent  by  extreme  extension  of  the  fingers,  the 


832  A  TEXT-BOOK   ON   SURGERY. 

edge  turned  upward,  and  a  thorough  division  effected,  taking  care  not 
to  allow  the  knife  to  cut  through  the  skin.  Every  resisting  band  should 
be  divided  until  the  fingers  can  be  readily  brought  into  a  position  of 
over-correction.  Two  or  three  lines  of  section  may  be  made  in  the  palm 
and  one  or  two  through  the  digital  prolongations  of  the  fingers  involved. 
By  carefully  inserting  the  knife  closely  beneath  the  fascia,  the  vessels 
of  the  palm  and  fingers  may  be  avoided.  The  palm  should  be  covered 
with  a  thick  layer  of  sublimate-gauze,  and  a  splint  applied  in  order  to 
keep  the  fingers  perfectly  straight.  This  should  be  worn  for  two  or 
three  weeks,  at  which  time  passive  motion  should  be  made  and  the 
splint  reapplied  for  another  week.  After  it  is  removed,  thorough  ex- 
tension should  be  practiced  at  least  once  a  day  for  several  months. 

Snap-  or  Jerk-Finger .—Ti\\%  name  has  been  used  to  designate  a  con- 
dition in  which  free  extension  and  flexion  of  one  or  more  fingers  is  more 
or  less  interrupted.  As  the  affected  digit  is  being  flexed  or  extended, 
motion  is  arrested  in  a  certain  position,  and,  if  a  violent  effort  is  made, 
or  if  flexion  is  continued  by  aid  from  the  other  hand,  a  perceptible  jerk 
occurs  as  the  obstruction  is  overcome.  A  nodular  swelling,  to  the  touch 
resembling  the  ganglia  often  met  with  on  the  back  of  the  wrist,  may  be 
felt  along  the  line  of  the  tendon  at  or  near  the  metacarpo-phalangeal 
joint.  Snap-finger  may  be  due  to  a  circumscribed  thickening  of  the  ten- 
don, or  a  disj)roportion  between  the  size  of  the  tendon  and  sheath  for  a 
limited  area.  This  condition  is  believed  to  exist,  especially  in  the  thumb, 
where  the  jerk  occurs  in  one  third  of  all  cases.  Mr.  Reeves  thinks  that 
in  the  fingers  it  is  chiefly  due  to  the  synovial  fringes  catching  upon  the 
transverse  process  of  the  palmar  fascia.  This  may  occur  not  only  "from 
thickening  of  this  process  of  fascia,  but  also  from  rolling  up  or  displace- 
ment of  the  synovial  sheaths." 

Snap-finger  m.ay  be  traumatic  or  idiopathic  in  origin.  Strains  on  the 
tendons  and  fascia  in  the  act  of  lifting,  direct  violence,  as  well  as  the 
gouty  and  rheumatic  inflammations,  are  noted  in  the  aetiology.  The 
treatment  consists  in  passive  motion,  and  internal  medication  to  correct 
any  dyscrasia.  If  relief  does  not  follow  ordinary  measures,  an  incision 
should  be  made  and  the  enlargement  dissected  out. 

In  certain  cases  in  which  adhesion  of  the  tendons  to  their  sheaths  and 
to  the  palmar  and  digital  fascia  occur  chiefly  as  a  result  of  penetrating 
wounds,  it  will — in  order  to  relieve  the  deformity — be  required  to  make 
an  open  dissection  and  divide  the  adhesions  in  plain  view.  Such  opera- 
tions can  be  done  with  impunity,  and  with  an  extraordinary  degree  of 
success,  if  the  strict  antiseptic  precautions  are  observed.  Esmarch's 
bandage  is  essential  to  the  operation,  and  cocaine  anaesthesia  I  have  fre- 
quently demonstrated  to  be  perfectly  satisfactory  in  these  procedures. 
The  wound  should  be  closed  at  once  with  fine  silk  sutures.  Catgut  is 
not  sufficiently  reliable  in  this  region.  The  danger  of  inflammation  and 
contractions  of  the  fascia  from  opening  into  the  hand  under  sublimate 
irrigation  and  careful  antisepsis  are  exceedingly  remote.  Even  the  most 
extensive  injuries  of  the  hand  may  be  made  to  heal  with  as  little  deform- 
ity as  often  follows  a  simple  wound  in  which  inflammation  and  suppu- 


ADHESION   OF   THE   TENDONS. 


833 


ration  are  established.  Figs.  753  and  752  are  taken  from  a  hand  one 
year  after  the  receij^t  of  a  gunshot-wound.  The  muzzle  of  the  piece  was 
in  contact  with  the  skin  at  the  time  of  the  explosion,  and  the  charge  of 


Fig.  751. — Gunshot-wound  of  the  hand.     Wound  of  entrance. 


small  shot  and  wadding  entered  at  the  palmar  aspect  of  the  little  finger, 
and  j)assed  out  through  the  metacarpal  bone  of  the  index -finger  and  to 
the  ulnar  side  of  the  thumb.     The  third  and  fourth  metacarpal  bones 


-d^- 


Fig.  752. — Wound  of  exit  of  the  charge. 


were  broken,  while  the  second  was  commimited  and  almost  all  of  it 
blown  away.  The  flexor  tendons  and  fascia  of  the  palm  were  torn  and 
divided.  The  treatment  consisted  in  immersion  of  the  member  in  1-to- 
2000  sublinjate  solution,  thorough  removal  of  powder  and  all  foreign 
matter,  reposition  of  attached  fragments  of 
bone  and  shreds  of  tendons,  fascia,  and  mus- 
cle in  as  near  their  normal  relation  as  pos- 
sible, and  applying  a  sublimate-gauze  dress- 
ing, placing  the  hand  in  the  natural  posi- 
tion and  holding  it  there  with  a  splint  and 
roller.  In  this  case  motion  was  secured  in 
every  finger,  and  no  contractions  of  the  fas- 
cia have  taken  place. 

53 


Fig.  753. — Deformity  resultins;  from 
exostosis.  (Alter  Annandale  and 
Noble  Smith.) 


834 


A   TEXT-BOOK   ON   SURGERY. 


Fig.  754. — Deformity  resulting  from 
chondroma  of  tlie  phalanges. 


When  the  tendons  are  divided,  either  in  the  foi-earm  near  the  wrist, 
or  in  the  palm  or  along  the  fingers,  it  is  essential  that  the  divided  ends 
be  stitched  together  with  silk  sutures.     Co- 
caine   anaesthesia    and    Esmarch's    bandage 
should  be  employed. 

Deformities  of  the  hand  and  fingers  also 
result  from  exostosis  and  new  formations  of 
cartilage  in  the  digits  (Figs.  753  and  754). 
Amputation  is  indicated  in  the  latter  condi- 
tion, while  in  exostosis  relief  may  be  ob- 
tained by  direct  incision  and  removal  of  the 
offending  bone. 

Phlegmon  of  the  Hand  and  Fingers. — 
Phlegmon  of  the  fingers  is  an  exceedingly 
l^ainful  affection.  Occurring,  as  it  usually 
does,  in  the  terminal  phalanx,  a  knowledge 
of  the  arrangement  of  the  fascia  here  is 
essential  to  proper  treatment.  Fig.  754  a  shows  the  intimate  attachment 
of  the  connective-tissue  fibers  to  the  integument  of  the  j)almar  aspect  of 
the  digit  and  to  the  matrix  of  the  nail,  the  separation  of  the  various 
layers  to  form  spaces  in  wMch  are  contained  quantities  of  fat.  The  gen- 
eral convergence  of  these  bundles  of  connective  tissue  toward  the  center 
is  well  illustrated  in"  the  cut.  They  are  intimately  attached  to  the  sheath 
of  the  tendon  in  front  and  to  the  periosteum  posteriorly.  The  lymph- 
channels  follow  the  layers  of  fascia  from  the  skin  toward  the  bone. 
Phlegmon  of  the  finger  ("/eZow,"  or  "zoAiYZow")  may  originate  in  the 
bone  or  periosteum,  but  most 
frequently  begins  in  the  soft 
tissues.     On  account  of  the  ar-       ^^ 

rangement    of    the    fascia    and      '  ^    /  \^^  '- 

lymphatics,     the    inflammation     /  -  "  ' 

rapidly  extends  to  the  tendon  or 
periosteum.  The  dense  struct- 
ure of  the  tissues  here,  which 
prevents  their  yielding  to  the 
pressure  of  the  inflammatory 
infiltration,  wDl  account  for  the 
unusual  degree  of  pain  present 
in  this  affection. 

Phlegmon  of  the  palmar  as- 
pects of  the  thumb  or  little  fin- 
ger, not  relieved  by  early  incis- 
ion and  disinfection,  may  ex- 
tend along  the  sheaths  of  their  tendons  and  invade  the  entire  palmar 
fascia.  Conversely,  central  phlegmon  of  the  palm  of  the  hand  may 
radiate  to  these  digits  (Fig.  754  b). 

By  reason  of  the  anatomical  arrangement  of  the  sheaths  of  the  ring, 
index,  and  middle  fingers,  closing  as  they  do  in  blind  extremities  at  the 


\ 


Fig.  754  a. — Showing  the  converging  arrangement  of  the 
dense  connective-tissue  hundles  in  the  tinger  around 
the  last  phalanx.     (After  Vogt.) 


PHLEGMON   OF   THE   HAND   AND   FINGERS. 


835 


metacarpo-phalangeal  articulations,  tlie  inflammatory  process  does  not 
extend,  as  a  rule,  into  the  large  synovial  sac  beneath  the  palmar  fascia 
(Figs.  754  B  and  754  c).  Upon  the  back  of  the  hand  and  fingers  phleg- 
mon behaves  as  it  does  beneath  the  skin  in  other  jaarts  of  the  body. 

In  the  treatment  of  wJiitlow 
the  first  indication  is  to  relieve 
tension  at  the  earliest  moment 
by  puncture   or  incision.      The 


Fig.  754  b — Shonm^  b\  iniLCtion  the  continuity 
of  tlie  sjno\ial  sheaths  ut  the  little  linger 
and  thumb  with  the  laige  sac  beneath  the 
palmar  fascia.     (After  Vogt.) 


Fig.  754  o. — Showing  at  A  A  A  the  sheaths  of 
the  ring,  middle,  and  index  fingers  ending 
in  blind  extremities  toward  the  palmar  sac. 
(Alter  Vogt.) 


exact  point  of  inflammation  in  the  earliest 
stage  of  ijhlegmon  may  be  recognized  by  di- 
rect pressure  viith.  a  small  pointed  instrument, 
as  a  probe  or  director.  Cocaine  may  be  util- 
ized to  prevent  pain  when  the  incision  is 
made.  A  rubber  ligature  tied  around  the 
finger  to  arrest  the  circulation,  and  a  few 
minims  injected  into  the  line  of  incision,  will 
deaden  all  sensibility.  The  incision  should 
be  free,  and  down  to  the  tendon  or  bone,  to 
insure  relief  of  all  tension.  The  part  should 
then  be  submerged  in  warm  sublimate  solu- 
tion, the  ligature  removed,  and,  after  a  min- 
ute or  two  of  bleeding  under  water,  an  iodo- 
form strip  should  be  packed  into  the  Avound, 
and  a  moist  aseptic  dressing  applied. 

When  pus  has  formed  and  can  be  evacu- 
ated in  this  manner,  the  opening  should  be 
made  upon  the  lateral  aspects  of  the  finger, 
in  order  to  avoid  the  sheath  of  the  tendon. 


Fig.  754  d. — Showing  outline  rem- 
tion  of  arteries,  and  line  of  incis- 
ion whicli  may  avoid  the  more 
important  vessels.    (After  Vogt.) 


836  A  TEXT-BOOK  ON   SURGERY. 

In  phlegmon  beneath  the  palmar  fascia  the  same  principles  of  in- 
cision and  drainage  should  be  applied,  avoiding  the  larger  vessels  when 
possible  (Fig.  754  d). 

Ganglion. — Ganglion  is  due  to  the  localized  collection  of  a  variable 
quantity  of  synovial  fluid  in  the  sheaths  of  the  tendons,  or  bursse  on 
the  dorsum  of  the  hand  or  wrist.  Excision  and  dissection  under  cocaine 
anaesthesia,  and  strict  asepsis,  I  have  found  to  be  the  most  satisfactory 
means  of  effecting  a  cure.  They  may  be  made  to  disappear  by  absorp- 
tion, after  subcutaneous  rupture  from  a  sharp  blow  with  the  back  of  a 
book  or  padded  hammer. 


CHAPTER  XXII. 


The  word  tumor  (from  tumere,  to  swell)  was  formerly  applied  to  any- 
abnormal  formation  or  collection  of  matter  within  the  body.  The  over- 
accumulation  of  fecal  matter  in  the  colon,  the  swelling  due  to  extravasa- 
tion of  blood,  or  to  the  retraction  of  a  muscle  after  rupture  of  its  tendon ; 
an  abscess,  a  retention-cyst,  a  hernia,  a  floating  or  displaced  kidney,  as 
well  as  all  the  recognized  non-inflammatory  neoplasms,  as  sarcoma,  fibro- 
ma, lipoma,  carcinoma,  etc.,  were  ranged  under  the  comprehensive  head- 
ing of  tumors. 

Of  late  years  the  application  of  the  term  has  been  more  restricted. 
A  tumor  is  now  defined  to  be  a  circumscribed,  non-injlavimatory  mass, 
composed  of  new-formed  elements  which,  having  their  type  in  the  nor- 
mal evibryonic  or  adult  tissues,  are  dependent  upon  these  for  nutrition, 
and  yet  are  not  amenable  to  the  laws  regulating  and  limiting  the  devel- 
opment of  the  normal  structures. 

Circumscribed,  because  a  general  or  wide-spread  hypertrophy  or  hy- 
perplasia does  not  convey  to  the  eye  or  touch  the  idea  of  a  swelling  or 
tumor.  The  accumulation  of  fat  in  obesity  can  not  be  called  a  tumor, 
yet  the  fat  so  deposited  over  a  wide  area  differs  in  no  essential  particular 
from  that  which  forms  a  lipoma. 

Non-inflammatory,  for  the  reason  that  this  most  clearly  separates 
true  neoplasms  from  the  cell-proliferation  of  the  ordinary  inflammatory 
process,  with  its  characteristic  heat,  pain,  and  redness,  as  well  as  swell- 
ing. 

JSfeio  formations  in  this,  that  although  the  law  established  by  Johan- 
nes Muller— that  the  elements  of  all  tumors,  no  matter  how  changed  from 
the  normal,  spring  from  and  have  their  types  in  the  normal  tissues  of 
embryonic  or  adult  life — stands  unquestioned,  yet  these  elements,  in 
their  changed  conditions,  tend  to  persist  or  to  grow  indefinitely,  in  utter 
disregard  of  the  laws  of  limitation  in  the  development  of  normal  tissues. 

The  efl'orts  at  classification  of  tumors  upon  a  histological  basis  have 
not  been  generally  satisfactory.  Virchow,  Foerster,  Cornil  and  Ranvier, 
and  other  pathologists,  with  the  same  end  in  view,  have  arrived  at  con- 
clusions scarcely  reconcilable.  A  discussion  of  these  various  classifica- 
tions belongs  more  properly  to  special  works  on  pathology.  Clinically, 
they  admit  of  division  into  two  heads— the  malignant  and  non-malig- 
nant. 


838  A  TEXT-BOOK   ON   SURGERY. 

Malignance/  in  a  tumor  means  its  tendency  to  become  multiple  by 
metastasis ;  the  tendency  of  tlie  elements  of  wMch  it  is  composed  to 
travel  along  the  lymph-  or  blood-channels,  and,  thus  disseminated,  to  re- 
produce the  parent  tumor  ;  or  its  tendency  to  invade  and  destroy  the  tis- 
sues in  its  vicinity,  and  to  recur  in  loco  after  extirjoation. 

Strictly  speaking,  the  tendency  of  a  neoplasm  to  induce  death  has 
nothing  to  do  with  the  question  of  its  malignant  character,  for  certain 
tumors,  as  fibro-myomata  of  the  uterus  and  simple  ovarian  cysts,  tend 
to  produce  death  as  well  as  carcinomata  and  sarcomata. 

The  malignant  neoplasms  are  grouj)ed  under  two  headings — carcino- 
ma and  sarcoma. 

The  non-malignant  are  as  follows  :  lipoma,  fibroma,  myxoma,  oste- 
oma, enchondroma,  angioma,  neuroma,  myoma,  adenoma,  papilloma, 
and  lymphoma. 

Carcinoma. — A  cancer  may  be  defined  to  be  a  tumor,  composed  of 
embryonic  cell-elements  of  varying  shape  and  proportions,  collected  in 
groups,  which  groups  or  clusters  are  jjartially  separated  by  a  well-defined 
stroma. 

While  the  elements  of  the  carcinomata  do  not  always  differ  so  widely 
from  those  of  the  sarcomata  (especially  the  more  embryonic  cells  of  this 
last,  neoplasm),  the  alveolar  structure  of  the  stroma  of  cancer  wiU  always 
render  it  easy  of  recognition. 


Fio.  755.— Development  of  carcinoma,     s,  Bundles  of  fibrous  tissue  containing  occasional  connective-tissue 
corpuscles,    a,  Cancer-cells  in  groups  or  rows  between  the  stroma.     (After  Comil  and  Kanvier.) 

Cancer-cells  vary  greatly  in  shape  and  dimensions,  being  round,  flat, 
ovoid,  fusiform,  polygonal,  and  measuring  from  ^^^  to  ^^  and  -g^^  inch 
in  diameter.     Each  cell  may  contain  one  or  many  nuclei.     The  nucleus 


CARCINOMA. 


839 


Fig.  756.— Stroma  of  cancer  from  which  the 
cell-elements  have  been  removed.  (After 
Comil  and  Eanvier.) 


is  often  of  large  size,  at  times  occupying  tte  greater  portion  of  the  cell- 
space.  The  nucleoli  are  especially  prominent.  The  cell-elements  of  car- 
cinoma are  contained  within  the  alveoli,  and  float  in  or  are  in  contact 
with  a  juice  of  varying  quantity  and  consistence. 

The  walls  of  the  alveoli  are  composed  of  a  fibrillated  structure  of 
modified  connective  tissue.     In  old  tumors  the  fibers  of  the  stroma  are 

closely  packed  together,  while  in  more 
recent  neoplasms  connective-tissue  cor- 
puscles are  frequently  observed  be- 
tween the  clusters  of  cells  (Fig.  755). 
The  alveolar  arrangement  of  the  stroma 
is  well  shown  in  Fig.  756,  in  which  the 
cancer-cells  have  been  removed. 

The  alveoli  are  not  isolated  cavi- 
ties, but  communicate  more  or  less 
freely.  In  the  connective-tissue  walls 
of  the  alveoli  the  blood-vessels  and 
lymph-channels  are  lodged.  In  the 
development  of  a  carcinoma  the  pro- 
liferation among  the  cells  proper  of 
the  neojDlasm  excites  a  similar  condi- 
tion in  the  connective-tissue  cells  of 
the  neighboring  and  involved  tissues, 
and,  coincident  with  the  multiplica- 
tion of  the  cancer-elements,  the  connective-tissue  elements  are  developed. 
In  this  way  the  stroma  is  formed  around  and  among  the  cancer-cells, 
and  in  rare  instances  this  proliferation  is  so  rapid  that  clusters  of  adipose 
cells  are  caught  within  the  neoplasm  and  remain  as  such  in  the  process 
of  growth  in  the  tumor. 

Carcinomata  spread  by  direct  invasion  of  contiguous  tissues,  and 
along  the  route  of  the  lymph-channels. 

It  is  not  uncommon  (as  established  by  Cornil  and  Ranvier)  for  indu- 
ration and  hypertrophy  of  the  ganglia  of  the  nearest  lymjDh-plexus  to 
occur  before  metastasis  has  taken  place,  a  fact  of  great  interest  to  the 
surgeon.  This  early  glandular  hyperplasia  is  due  to  the  irritation  caiised 
by  the  neoplasm,  and  though  less  acute  is  not  unlike  the  adenitis  of  an 
ordinary  inflammatory  process. 

Three  chief  varieties  of  cancer  are  recognized — the  scirrTius,  enceplia- 
loid,  and  mucoid  or  colloid.  EpitlieUoma  will  also  be  included  under 
this  heading. 

Scirrhus,  or  hard  cancer,  is  distinguished  by  the  greater  proportion 
and  thickness  of  the  stroma,  in  comparison  with  the  cell-elements.  Many 
of  the  cells  in  this  variety  of  neoplasm,  especially  those  more  deeply  situ- 
ated, undergo  extensive  granular  metamorphosis,  and  appear  as  granular 
corpuscles,  having  lost  all  the  characteristics  of  the  cancer- elements. 

Encephaloid,  soft,  or  medullary  cancer  is  rich  in  cells  and  cancer- 
juice,  while  the  stroma  is  very  thin.  It  is  more  vascular,  and  in  gross 
appearance  is  like  broken-up  brain-matter  ;  hence  the  name  encephaloid. 


840  A  TEXT-BOOK   ON  SURGERY. 

Owing  to  the  embryonic  character  of  the  new-formed  blood-vessels  and 
the  lack  of  resistance  from  the  scantily  developed  stroma,  aneurismal 
dilatations  of  the  vessels  are  common,  and  rupture  frequently  occurs. 

Colloid  cancer  is  characterized  by  the  presence  within  the  alveoli  of  a 
fluid  rich  in  mucin,  which  substance  also  appears  in  all  the  foci  that  may 
be  developed  by  metastasis.  Many  of  the  cells  disapiDear,  and  those 
which  remain  are  unusually  large  and  swollen.  The  alveoli  are  also  dis- 
tended and  the  walls  more  translucent  than  in  scirrhus. 

The  changes  which  cancers  undergo  are  chiefly  granular  metamorpho- 
sis and  ulceration.  The  cells  of  the  deeper  portions  of  the  neoplasm,  de- 
prived of  sufficient  nourishment  by  reason  of  their  central  position,  break 
down  in  a  granular  detritus,  which  is  absorbed  and  carried  away  in  ]3art 
by  the  blood-vessels,  but  chiefly  by  the  lymph-channels.  In  older  tumors 
this  gradual  loss  of  cellular  elements  is  followed  by  contraction  of  the 
stroma  and  sinking  in  or  retraction  of  the  integument.  Inflammation 
and  iilceration  of  a  cancer  may  result  from  direct  irritation  from  without, 
or  may  occur  as  a  result  of  the  growth  of  the  neoplasm,  which  thus  often 
cuts  off  its  own  nutrition.  The  process  is  not  unlike  ulceration  in  the 
normal  tissues,  only  the  granulations  are  often  very  exuberant  and  the 
death  of  tissue  rapid.  All  forms  of  carcinoma  are  subject  to  the  deposit 
of  pigment,  and  under  such  conditions  have  been  termed  melanotic 
cancer. 

CfctMse^f.— Cancer  is' a  disease  of  adult  and  of  late  adult  life.  Scirrhus, 
encephaloid,  or  colloid  cancer,  under  twenty  years  of  age,  is  exceedingly 
rare.  It  occurs  chiefly  in  the  period  of  life  between  thirty  and  sixty. 
Women  are  more  frequently  attacked  than  men.  The  influence  of  he- 
redity upon  the  j)roduction  of  carcinoma  is  believed  to  be  established, 
although  its  importance  has  been  greatly  overestimated.  Prolonged 
irritation  is  undoubtedly  the  chief  exciting  cause  of  the  development  of 
this  neoplasm.  In  evidence  of  this  conclusion  is  the  fact  that  those  por- 
tions of  the  body  which  are  subjected  to  the  greatest  amount  of  irrita- 
tion are  most  often  affected.  The  mammary  gland,  jjylorus,  rectum,  and 
uterus,  are  the  more  common  locations  of  cancer. 

Diagnosis. — The  recognition  of  cancer  is  positive  only  by  microscop- 
ical examination,  and  depends  in  part  upon  the  peculiar  characters  of 
the  cells  already  noted,  but  chiefly  upon  the  appearance  of  the  stroma. 
Clinically,  the  diagnosis  will  depend  upon  the  age  of  the  patient,  the 
location  of  the  tumor,  its  consistence,  immobility,  and  the  condition  of 
the  lymphatic  glands  in  the  line  of  the  vessels  toward  the  center.  A 
tumor  occurring  between  the  ages  of  thirty  and  sixty,  of  a  mildly  pain- 
ful character,  the  pain  sharp  and  lancinating,  and  increased  when  firm 
pressure  is  exercised ;  steadily,  although  at  times  slowly,  enlarging, 
movable,  it  may  be,  beneath  the  skin  or  vsdthin  the  substance  of  the 
organ  or  part  in  which  it  is  located,  yet  not  freely  so,  should  be  looked 
upon  with  suspicion.  If  it  has  existed  for  several  months,  and  there  is 
retraction  of  the  integument  over  a  portion  of  the  mass,  together  with 
induration  of  the  nearest  lymphatic  glands,  the  diagnosis  of  cancer  is 
almost  positive.     As  between  the  three  different  forms  of  cancer,  it  may 


EPITHELIOMA.  841 

be  said  that  scirrlius  is  mucli  tlie  more  common,  is  slower  in  growth, 
and  harder  to  the  feel.  Colloid  is  also  hard,  and  grows  slowly,  and 
from  palpation  and  inspection  can  not  be  differentiated  from  scin-hus 
with  any  certainty.  It  is  comparatively  rare.  Encephaloid  is  a  soft, 
elastic  tumor,  not  always  of  uniform  consistence,  but  generally  of  smooth 
surface,  and  always  of  rapid  growth.  Its  vascularity  is  therefore  miich 
more  noticeable  than  that  of  either  of  the  other  varieties,  and  metastasis 
is  more  rapid.  As  between  sarcoma,  the  chief  diagnostic  points  are  the 
age  of  the  patient,  sarcoma  being  more  common  in  the  young,  cancer  in 
the  old  and  middle-aged  ;  the  lymi^hatics  are  not  involved  in  sarcoma, 
except  when  extensive  iilceration  and  septic  absorption  occurs ;  in  gen- 
eral, the  superficial  veins  of  sarcoma  are  more  dilated  and  perceptible, 
and  the  tumor  more  elastic. 

As  far  as  the  treatment  is  concerned,  the  differentiation  between  car- 
cinoma and  sarcoma  is  not .  essential.  The  indication,  when  operative 
interference  is  at  all  Justifiable,  is  extirpation  of  the  mass  by  a  dissection 
which  should  be  well  away  from  the  limits  of  the  neoplasm.  In  cancer 
the  neighboring  lymphatic  glands  should  be  extirpated  if  metastasis  has 
occurred,  while  in  sarcoma  this  is  not  indicated.  In  fact,  in  all  neoplasms 
not  positively  innocent,  removal  should  be  made  imiDerative.  The  shght- 
est  doubt  of  the  character  of  the  tumor  is  entitled  to  the  interpretation  of 
malignancy,  the  justification  of  this  conclusion  being  found  in  the  well- 
established  fact  that  an  innocent  neoplasm  may  become  malignant. 

The  excision  of  a  portion  of  a  tumor  for  microscopical  examination 
for  purposes  of  diagnosis  will  rarely  be  justifiable.  Any  irritation  of  the 
mass  is  reprehensible,  since  metastasis  is  more  apt  to  occur  under  such 
conditions. 

EpltTieUoma. — An  epltJieUoma  may  be  defined  as  a  neoplasm,  the 
embryonic  elements  of  which  assume,  in  a  varying  degree,  the  shape  and 
arrangement  of  the  normal  epithelium.  Developing  usually  in  the  skin 
or  mucous  membranes,  they  at  times  originate  in  tissues  remote  from 
them,  as  in  the  bones. 

Malignant  epitheliomata  may  be  di^^ided  into  two  classes  :  1,  the  lob- 
ular ;  2,  the  tubular.  Tubular  epithelioma  may  consist  of  {a)  flat  or 
round  cells,  ib)  columnar  or  cylindrical  cells. 

The  first  variety  is  by  far  the  more  common,  and  of  greatest  clinical 
interest.  It  occurs  by  preference  upon  the  muco-cutaneous  surfaces,  as 
the  lips,  prepuce,  anus,  vulva,  etc.,  but  may  appear  either  upon  the  skin 
or  mucous  surfaces,  remote  from  any  line  of  union  of  these  coverings,  as 
the  tongue,  cheek,  face,  etc. 

Epithelioma  usually  begins  as  a  nodule  or  induration  of  small  size, 
slightly  reddened  at  its  margin,  the  center  of  which  very  early  in  its  his- 
tory breaks  down  into  a  dirty  ulcer  which,  when  kept  fairly  clean,  is 
reddish  in  color,  and,  when  not  cleansed,  is  covered  with  a  grayish  mass 
of  pus  and  broken-down  tissue,  either  solidified  into  a  crust  or  scab, 
or  in  a  softened  state.  The  margins  of  the  ulcer  are  sinuous,  hard,  and 
everted.  It  may  limit  itself  to  a  small  area,  or  develop  steadily,  and 
sometimes  with  great  rapidity  until,  after  extensive  destruction  of  the 


842 


A  TEXT-BOOK   ON  SURGERY. 


(^ 


tissues  in  its  neighborliood,  death  ensiies  from  ligemorrhage,  sepsis,  or 
metastasis.  Pain  is  always  a  symptom  of  this  disease.  Lymphatic  en- 
gorgement may  occur  in  the  first  few  weeks,  but  usually  from  four  to 
eight  months,  and  even  a  longer  time,  may  elapse. 

Examined  microscopically,  this  form  of  epithelioma  is  seen  to  be 
composed  of  flattened  cells,  containing  one  or  several  nuclei,  with  a  tend- 
ency on  the  part  of  the  elements  to  form 
themselves  in  concentric  layers  (Fig.  757). 
In  the  center  of  these  spheres  of  flattened 
epithelia  are  frequently  seen  a  few  cells 
which  have  undergone  the  colloid  change. 
Farther  out  the  surrounding  cell-elements 
are  more  embryonic  in  character,  cylindri- 
cal, spherical,  or  polygonal  from  lateral 
compression,  the  mass  being  limited  ex- 
ternally by  a  stroma  of  connective  tissue, 
varying  in  quantity,  which  separates  one 
epithelial  nest  from  the  others  composing 
the  entire  neoplasm.  In  the  process  of 
ulceration  an  epithelioma  is  surrounded 
by  a  zone  of  embryonic  tissue  due  to  the 
cell-proliferation  of  the  inflammatory  pro- 
cess. 

Flat  or  Round,  and  Columnar  or 
Cylindrical-Cell  EpitlieUoma.  — Tubular 
epitheliomata  are  somewhat  less  malig- 
nant than  the  lobular  or  bird's-nest  variety  just  described.  After  reach- 
ing a  certain  stage  in  their  develojjment,  they  may  remain  stationary  ; 
but,  in  the  majority  of  instances,  the  tendency 
is  to  grow,  as  well  as  to  recur  after  removal. 
They  are  usually  situated  upon  the  skin,  where 
they  originate  in  the  sweat-glands  or  upon  the 
mucous  membranes,  where  they  spring  from 
the  follicles  of  these  surfaces.  The  antrum 
maxillare  is  occasionally  the  seat  of  this  variety 
of  neoplasm. 

Microscopically,  the  flat-celled  epitheliomata 
are  composed  of  pavement  or  tesselated  cells, 
crowded  in  tubiiles  or  cylinders,  which  are  long, 
more  or  less  irregular  in  shape,  at  times  anas- 
tomosing with  each  other,  and  are  held  togeth- 
er by  a  stroma  of  connective  tissue  (Fig.  758). 

The  general  shape  of  these  neoplasms  is 
oval  or  round.  They  grow  more  slowly  than 
the  preceding  variety. 

Columnar-celled  cylindrical  epithelioma  is 
met  with  in  the  deeper  organs,  as  the  aliment- 
ary canal  and  other  abdominal  viscera,  uterus. 


767. — Lobular  or  spherical  epitlieli- 
oraa,  250  diameters.  (Alter  Cornil 
and  Eanvier.) 


^i;, 


\'. 


\\ 


NfeS^ 


epit 
Dcler 


a,  Tubules  or  cylinciers  cut  ob- 
liquely. 6,  Connective-tissue 
stroma.  (After  Cornil  and 
Eanvier.) 


lt:mphadexoma. 


843 


OTaries,  etc.  It  differs  from  the  preceding  in  the  shape  of  the  epithelia 
which  line  the  tubules.  The  cells  are  columnar,  set  on  end,  contain  one 
or  more  nuclei,  and-  may  exist  in  a  single  layer  or  as  several  rows  of 
cells  piled  on  each  other.  The  framework  or  stroma  is  composed  of 
connective  tissue,  which  may  have  a  fibrillated  an-angement,  or  it  may 
remain  in  an  embryonic  condition  (Fig.  759). 

The  prognosis  of  these  tumors  is  unfavorable.  They  are  rarely  rec- 
ognized at  a  period  early  enough  in  their  history  to  allow  of  a  thorough 
removal.  Those  of  the  os  and  cervix  uteri,  ovaries,  rectum,  and  nose  are 
most  easily  removed. 


Fig.  T59. — Tubular  epithelioma  ■nith  cvlindrical  ele- 
ments, a.  Tubule  cut  across.  6,  'Cubule  cut  in 
its  long  axis,  c^  Cylindrical  epithelia.  (After 
Coruil  and  Eanvier.j 


Fig.  too. — Eeticular  structure  of  a  lymphatic  in- 
testinal follicle,  a  i.  Capillary  "vessels  with 
nuclei  in  their  walls,  c,  ileshes  of  the  retic- 
ular structure  containing  lymphatic  corpus- 
cles.    (Aiter  Frey.) 


LympTiadenoma. — This  variety  of  neoplasm  is  entitled  to  be  classed 
with  the  malignant  tumors.  It  consists  of  new-formed  lymphatic  gland- 
rissue,  and  may  occur  in  pre-existing  glands  or  in  any  of  the  tissues  of 
the  body.  The  liver,  spleen,  and  kidneys,  the  testicle,  the  alimentary 
canal,  the  bones  and  integument,  may  all  be  the  seat  of  these  new  forma- 
tions. Coincident  with  the  development  of  these  neoplasms,  the  pro- 
portion of  white  blood-corpuscles  in  the  volume  of  blood  is  enoiTQously 
increased,  until  death  ensues  from  leucocythaemia.  These  tumors  may 
be  of  any  size,  from  a  millet-seed  up  to  several  inches  in  diameter,  are 
soft  to  the  touch,  and  usually  not  well  defined.  They  can  not  be  diag- 
nosticated from  other  gland-tissues  unless  examined  microscopically, 
when  they  are  seen  to  consist  of  a  connective-tissue  framework  or  reticu- 
lum, along  the  fibrillse  of  which  run  the  capillaries,  and  in  the  meshes  of 
the  reticulum  the  lymph-corpuscles  are  situated  (Fig.  760). 

The  prognosis  is  grave,  and  the  condition  does  not  justify  surgical  in- 
terference. 

Sarcoraata. — A  sarcoma  is  a  tumor  the  elements  of  which  have  their 
type  in  the  normal  connective  tissues.  The  cells  of  a  sarcoma  may  be 
purely  embryonic,  or  may,  in  a  certain  sense,  resemble  the  more  devel- 
oped elements.  They  are,  however,  not  callable  of  organization  into  a 
permanent  tissue. 

Classified  according  to  the  shape  and  size  of  the  cell-elements  which 


844  A  TEXT-BOOK  ON  SURGERY. 

preponderate  in  their  composition,  tliey  are  called — 1,  round;  2,  spindle; 
3,  giant-cell  sarcoma. 

The  cell-elements  of  the  sarcomata  not  only  vary  in  size  and  shape, 
but  in  the  number  of  their  nuclei,  of  which  there  may  be  from  one  to 
thirty  or  more.  In  the  more  fully  developed  or  spindle-celled  neoplasm, 
the  elements  are  arranged  in  bundles  which  run  in  all  directions.  These 
tumors  possess  little  or  no  intercellular  substance,  the  elements  resting 
in  contact  or  separated  by  the  blood-vessels  which  freely  permeate  them. 
The  richness  of  the  blood-supply  and  the  proportion  of  the  tumor  occu- 
pied by  these  channels  are  well 
shown  in  Fig.  761. 

The  size  and  number  of  the 
blood-channels  depend  upon  the 
structure  of  the  tumor,  the  round- 
ceU  sarcoma  being  most  vascular, 
while  the  vessels  are  less  numerous 
and  of  smaller  caliber  in  the  spindle- 
cell  variety. 

The  intercellular  substance  also 
varies  in  quantity,  being  scarcely 
perceptible  in  the  round-cell  tumor, 
and  more  distinct  in  the  spindle  or 

J.      . »  .    .  T        •  J!    J.1  J^io-   '61- — Iniection  of  the  vascular  network  of  an 

fusiform    variety.       In    some    of    the  osteo-sarcoma.     (After  Billroth.) 

sarcomata  normal  connective-tissue 

fibers  may  exist,  and  these  are  believed  to  have  been  caught  in  the  de- 
velopment of  the  neoplasm. 

The  sarcomata  in  general  develop  with  great  rapidity,  and  tend  to  in- 
vade or  infiltrate  the  structures  in  their  immediate  neighborhood.  In 
this  the  different  forms  of  tumor  also  differ.  The  round-celled  neoplasm 
grows  more  rapidly  than  the  others,  and  is  more  apt  to  invade  the  sur- 
rounding tissues  than  the  fusiform-cell  variety.  It  is  not  the  rule  for 
these  neoplasms  to  become  encapsuled,  although  this  may  occur  in  the 
spindle-  or  giant-cell  variety. 

The  three  varieties  of  cells  may  exist  in  the  same  tumor.  According 
to  Cornil  and  Ranvier,  a  careful  search  will  reveal  the  presence  of  giant 
cells  in  varying  numbers  in  almost  all  sarcomata. 

The  retrogressive  changes  which  these  tumors  undergo  are  fatty  and 
calcareous  degeneration.  The  deeper  cells  of  tumors  of  considerable  size 
— in  other  words,  those  farthest  removed  from  the  supjjly  of  nutrition — 
very  commonly  undergo  the  fatty  or  granular  metamorphosis.  Not  in- 
frequently this  granular  metamorphosis  proceeds  so  rapidly  that  the 
blood-vessels  of  the  tumor  become  occluded  with  the  fatty  detritus  (gran- 
ular infarction).  In  this  way  the  nutrition  in  certain  portions  of  the 
growth  is  interfered  with,  increasing  the  area  of  fatty  metamorphosis,  or 
inducing  gangrene  from  a  sudden  arrest  of  the  blood-current. 

Calcareous  degeneration  occurs  in  certain  of  the  sarcomata  irrespect- 
ive of  their  being  situated  in  the  neighborhood  of  bone.  Pigmentation 
occasionally  occurs,  and  this  form  is  at  times  separately  classified  as  me- 


SARCOMATA.  845 

lanotic  sarcoma.  It  is  apt  to  take  place  in  the  small,  round-cell  tumors. 
Acute  inflammation  in  a  sarcoma  is  almost  always  followed  by  the  pro- 
liferation of  an  exuberant  granulation-tissue,  with  more  or  less  extensive 
gangrene  and  death  of  the  mass.  Excessive  and  at  times  fatal  hsemor- 
rhage  may  occur  in  the  process  of  sloughing. 

A  common  accident  in  the  evolution  of  a  sarcoma  is  the  extravasation 
of  blood  from  rupture  of  the  walls  of  the  new-formed  vessels.  Such  is 
the  crude  condition  of  these  tumors  that  even  the  cells  which  compose 
the  vessels  are  embryonic,  and  readily  give  way,  allowing  the  escape 
of  blood  among  the  ceU-elements  and  intercellular  spaces.  The  more 
nearly  the  development  of  the  cells  approaches  a  normal  tissue,  the 
less  probability  there  is  of  extravasation.  The  blood  thus  escaped 
may  be  absorbed  or  become  encapsuled  by  pressure  upon  the  cells  near 
the  ];)oint  of  rupture  and  become  converted  into  a  blood-cyst. 

Mucoid  degeneration  is  also  occasionally  met  with 
^^^  .>4  r^        1^  these  neoplasms.     The  cells  of  certain  portions  of 
^  \       the  tumor  'disappear,  leaving  cysts  or  alveoli  varying 

"*'  '  ,      in  size  from  the  smallest  up  to  as  large  as  two  or 

,      three  inches  in  diameter  in  large  tumors.     The  cysts 
are  occupied  by  an  amber-colored  or  reddish-brown 
iiuid,  which,  examined  with  the  microscope,  demon- 
strates the  presence  of  blood-corpuscles  in  various 
conditions  of  degeneration.     Chemically,   the  fluid 
J»ma.  "(Atter^Gnj'enT'     yields  mucin.     The  name  alveolar  sarcoma  (Fig.  762) 
has  been  given  to  this  form  of  tumor. 
Clinical  Features. — Sarcomata  maybe  met  with  in  all  conditions  and 
at  any  period  of  life.     Compai-atively  speaking,  they  are  rare  in  old  age, 
occurring  chiefly  in  children  and  adults  under  thirty.     Occasionally  they 
are  congenital.     Both  sexes  are  equally  liable  to  be  attacked.     They  are, 
as  a  rule,  idiopathic  in  origin,  in  rare  cases  being  due  to,  or  at  least  fol- 
lowing, an  injury  to  the  part  involved  in  the  neoplasm.     Sarcomata  are 
among  the  most  malignant  new  formations,  not  only  recurring  in  loco 
after  removal,  but  tending  to  be  disseminated  by  the  blood-vessels.     Un- 
like the  carcinomata,  they  have  no  lymph-channels,  and  metastasis  must 
occur  by  the  blood-vessels  which  enjoy  free  anastomoses  with  the  caverns 
and  sinuses  of  the  neoplasms. 

The  degree  of  malignancy  of  a  sarcoma  is,  in  general,  in  proportion 
to  the  embryonic  character  of  the  elements  of  which  it  is  composed. 
Thus,  the  round-ceUed  tumors  of  rapid  development  are  most  malignant, 
the  spindle-celled  next,  the  giant-celled  last  in  this  order. 

As  to  location,  no  tissue  is  exempt.  They  are  frequently  met  with  in 
the  skin  and  subcutaneous  tissues  (Fig.  763) ;  also  the  osseous  tissues, 
especially  the  long  bones,  furnish  a  favorite  seat  for  them.  Those  devel- 
oping from  within  are  chiefly  the  myeloid  or  giant-celled  variety  ;  those 
of  periosteal  origin  are  round-  or  spindle- celled. 

Sarcoma  of  the  bones,  according  to  Prof.  S.  W.  Gross,  who  has  writ- 
ten a  most  exhaustive  paper  upon  this  subject,  is  exceedingly  malignant, 
being  only  second  to  cancer  of  the  soft  tissues. 


846 


A  TEXT-BOOK   ON  SURGERY. 


-Sarcoma  of  the  scalp  and  neck. 


From  tlie  foregoing  it  is  evident  that  tlie  prognosis  in  any  of  the  vari- 
eties of  sarcoma  is  unfavorable.  The  gravity  is  increased  with  the  dura- 
tion of  the  tumor,  its  location  near  the 
trunk,  and  vi^ith  the  rapidity  of  its 
growth. 

The  round-celled,  especially  those 
which  have  undergone  the  melanotic, 
mueoid,  or  alveolar  change,  are  most 
dangerous  ;  next,  the  spindle-celled, 
and,  lastly,  the  myeloid  or  giant-celled 
variety. 

The  Treatment. — Situated  superfi- 
cially, or  in  the  soft  parts,  they  should 
be  excised  as  soon  as  observed.  The 
incision  should  always  be  wide  of  the 
suspected  limit,  and  the  skin  and  all 
the  tissues  should  be  removed  well  be- 
yond the  tumor.  AVhen  a  bone  is  the 
seat  of  the  new  formation,  no  effort  should  be  made  to  preserve  the  peri- 
ostenm.  The  bone  should  be  divided  as  far  beyond  the  lesion  as  may  be 
deemed  consistent  with  the  safety  of  the  patient  and  the  preservation  of 
the  function  of  the  part  involved. 

When  a  sarcoma  is  developed  upon  an  extremity,  if  it  be  small  or  of 
very  recent  date,  a  wide  extirpation  should  be  undertaken  ;  but,  if  there 
is  at  any  time  thereafter  an  indication  of  recurrence,  amputation  should 
be  considered. 

Sarcoma  of  the  bones  of  the  extremity  calls  for  immediate  amputa- 
tion.    If  the  tibia  is  involved,  disarticulation  at  the  knee  is  indicated. 
If   the  neoplasm  is  located  in  the  femur  below  the  middle,  the  bone 
should  be  removed  at  the  hip.     If  the  soft  parts  are  not  involved,  a  long 
flap  should  be  made,  and  the  femoral  vessels  divided  as 
(igSlgini,,  ,^  -low  down  as  possible. 

Special  Forms  of  Sarcoma — Round-Cell  Variety. — 
The  cells  are  analogous  to  the  embryonic  elements  of  the 
ordinary  inflammatory  process  from  which  they  can  not 
be  distinguished.  They  possess  one  or  more  nuclei  and 
micleoli,  and  are  spherical,  or  with  slightly  irregular  out- 
lines from  reciprocal  pressure.  The  intercellular  sub- 
stance is  homogeneous,  and  either  very  scanty  or  entirely 
absent  (Fig.  764).  The  vessels  and  blood-channels  have 
been  described.  This  variety  of  sarcoma  occurs  every- 
where. In  the  neuroglia  of  the  brain  and  the  neurilemma  elsewhere  it 
has  been  called  neurosarcoma  or  glioma. 

Spindle-Cell  Sarcoma. — The  cells  of  this  variety  are  elongated  or 
fusiform  in  shape,  containing  usually  one,  at  times  several,  nuclei.  The 
ends  of  the  spindle  may  be  single  or  bifurcated  (Fig.  765).  The  cells 
vary  in  size  from  ^-g^-^  to  too  of  ^^'^  inch  in  diameter,  and  are  arranged  in 
bundles  running  in  various  directions  (Fig.  766). 


■:\^ 


Fia.  V64.— Eound- 
cell  sarcoma. 
(After  Grocn.; 


GIANT-CELL  SARCOMA. 


847 


Clinically,  this  is  the  most  common  form  of  sarcoma.  They  are  slower 
in  development,  firmer  to  the  feel,  and  less  vascular,  and  of  smaller 
dimensions  than  the  preceding  variety.     As  stated,  they  are  somewhat 


Fig.  765. — Multipolar  cells  of  a  sarcoma.    (After  Cornil  and  Kanvlcr.) 

less  malignant.  They  may,  in  rare  instances,  be  encapsuled,  although 
the  rule  is  to  invade  the  surrounding  tissues.  The  favorite  location  for 
their  development  is  the  periosteum  and  in  the  substance  of  the  bones. 


Fig.  760. — Spindle-cell  sarcoma.     (After  Vii-chow.) 

They  attack  the  glandular  structures,  not  infrequently  affecting  the 
breast.  While  developing  here,  the  increased  vascularity  of  the  neo- 
plasms induces  hyperemia  of  the  glandular  apparatus  of  the  breast  with 
consequent  proliferation  of  the  epithelia,  a  condition  which  has  been 
termed  by  Billroth  adeno-sarcoma. 

Giant-Gell  Sarcoma. — The  cells  of  this  neoplasm  are  of  all  sizes  and 
shapes:  spherical,  fnsiform,  and  irregularly  oval,  having  at  times  one, 
at  others  thirty  or  more  nuclei  (Fig.  767).  They  closely  resemble  the 
cells  of  the  normal  marrow  of  foetal  bones.  Clinically,  this  form  of  sar- 
coma is  met  with  usually  in  the  bones,  especially  in  the  lower  jaw  and 


848 


A  TEXT-BOOK   ON  SlIRGERY. 


the  long  bones.  It  may  develop  to  an  enormous  size,  remaining  practi- 
cally confined  to  a  single  bone ;  less  frequently  spreading  to  the  sur- 
rounding soft  parts.  Bones  so  affected  at  times  become  friable,  being 
readily  fractured  from  the  body-weight,  or  yield  a  crackling  sound  upon 
palpation.* 


Fig.  767. — Giant-cell  sarcoma.    From  a  sarcoma  of  bone.     (After  Ordonez.; 


NON-MALIGNANT  NEOPLASMS. 

The  non-malignant  epitheUomata  are  the  dry,  pavement,  or  pearl- 
like epithelioma,  papilloma,  the  adenoma,  and  the  cystic  tumors. 

The  pearl  epithelioma  is  of  rare  occurrence.  Microscopically,  it  is 
found  to  be  closely  akin  to  the  bird's-nest  tumors,  which  are  classed 
with  the  malignant  growths.  The  cells  of  the  non-malignant  and  rare 
neoplasm  are,  however,  flat,  and  collected  in  little  dry,  pearl-like  bodies, 
gathered  in  clusters,  and  held  together,  or  surrounded  by  a  connective- 
tissue  stroma.  Occasionally,  cholesterine  crystals  are  seen  in  these 
bodies,  and  this  fact  induced  Miiller  to  name  this  form  of  neoplasm 
'■'•cholesteatoma.'''' 

The  proper  treatment  is  removal  with  the  knife. 

Papilloma. — A  pa]pilloma  is  a  neoplasm,  in  structure  not  unlike  the 
normal  papillse  of  the  skin  and  mucous  membranes.     Each  papilla  pos- 

•  *  For  a  consideration  of  the  varioaa  mixed  varieties  of  sarcoma,  viz.,  osteoid,  nenro-  and 
lipo-sarcomata,  angiolithic  sarcoma,  etc.,  the  student  is  referred  to  the  text-boolis  on  pathology, 
and  especially  to  the  excellent  work  of  Cornil  and  Eanvier,  which  the  author  has  drawn  from 
extensively.  5 


ADENOMA.  849 

sesses  a  connective-tissue  framework  which  supports  one  or  more  new- 
formed  vascular  loops,  and  the  whole  is  covered  in  with  one  or  several 
layers  of  epithelia. 

They  may  be  met  with  upon  the  cutaneous,  mucous,  or  serous  sur- 
faces. 

The  most  frequent  form  of  papilloma  is  the  ordinary  "wart."  The 
hard  or  cutaneous  wart  is  often  seen  upon  the  hands ;  the  soft  or  mu- 
cous wart  is  frequently  met  with  upon  the  prepuce,  vulva,  and  anal 
margins.     Corns  are  also  classified  as  papillomata. 

Mucous  warts  grow  more  exuberantly  than  those  of  the  skin.  Upon 
the  prepuce,  where  they  are  kept  moist  and  are  subjected  to  irritating 
secretions  and  to  friction,  they  fonn  at  times  enormous  masses.  Heem- 
orrhage  is 'a  common  accident,  and  sloughing,  with  the  emission  of  a 
most  offensive  odor,  is  the  rule  in  these  larger  neoplasms. 

Essentially  benign  papillomata  may,  by  long-continued  irritation,  be 
converted  into,  or  replaced  by,  an  embryonic  neoplasm  of  a  malignant 
type. 

Treatment. — The  indication  is  to  destroy  them  at  once.  The  best 
method  to  pursue  is  to  grasp  them  with  forceps,  clip  them  off  with  scis- 
sors close  to  the  attached  margin,  and  apply  nitric  acid  to  the  bleeding 
base  of  the  neoplasm.  Ansesthesia  is  obtained  by  moistening  them  for 
several  minutes  with  a  4-per-cent  solution  of  cocaine  hydrochlorate.  The 
nitric  acid  leaves  a  yellow  stain,  which  is  objectionable  when  the  growth 
is  situated  upon  an  exj)osed  surface. 

Adenoma. — Adenomata  are  neoplasms  the  structure  of  which  is  analo- 
gous to  gland-tissue.  Following  this  analogy,  they  are  of  the  racemose 
and  tabular  varieties.     The  racemose  adenomata  are  extremely  rare. 


i-6 


.1 
"3  6 


Fig    7S8.— f^aial  polypus,    a,  Pavement  epithelia,  of  wluch  the  deeper  laytr^,  d,  aio  lj  linili ical,  and  are 
arranged  along  the  edges  of  the  papillae,  h.    A  vessel  is  shown  at  b.    (After  Cornrl  and  lianvior.) 

They  are  composed  of  collections  of  acini  held  together  by  a  varying 
quantity  of  connective  tissue,  and  lined  with  epithelium.  They  may 
develop  in  all  parts  of  the  economy  where  the  racemose  glands  are 


850  A  TEXT-BOOK  ON  SURGERY. 

found.  A  favorite  location  is  the  mammary  gland,  occasionally  in  the 
parotid,  the  lachrymal  gland,  and  the  roof  of  the  mouth.  They  are 
slow  in  growth,  are  spherical  in  shape,  and  are  freely  movable  in  the 
structure  in  which  they  develop. 

Tubular  adenoma  is  more  frequently  observed  than  the  racemose  va- 
riety. The  tubules  are  in  some  cases  separated  by  a  layer  of  new-formed 
connective  tissue,  while  in  others  there  is  no  perceptible  intertubular 
stroma.  The  tubules  may  be  single,  but  are  more  frequently  bifurcated, 
and,  as  in  the  normal  glands,  commence  in  blind  extremities  and  open 
upon  the  mucous  surface.  They  are  lined  with  one  or  more  layers 
of  glandular  epithelium.  These  tixmors  are  seen  in  the  rectum  and 
colon,  in  the  uterus,  especially  the  cervix,  and  occasionally  in  the  nose 
(Fig.  768). 

They  are  spherical  or  pyriform  masses,  covered  with  mucous  epithe- 
lium as  long  as  they  are  contained  within  the  cavities ;  but  when,  by 
reason  of  excessive  growth,  they  are  exposed  to  the  air,  the  covering  be- 
comes hard  and  smooth,  like  the  epidermis. 

Cysts. — A  cyst  is  a  tumor  composed  of  a  limiting  membrane  or  cap- 
sule of  connective  tissue,  lined  by  epithelium  and  tilled  with  fluid  or 
semi-fluid  contents.  The  contained  matter  may  be  mucoid  or  colloid 
material,  or  sebaceous  matter  and  epithelial  cells  in  various  conditions  of 
degeneration. 

Sebaceous  cysts  oacwv  upon  all  portions  of  the  external  surface,  and 
in  rare  instances  develop  in  the  deeper  tissues. 

The  external  sebaceous  tumors  are  seen  very  frequently  upon  the 
face  and  scalp,  and  vary  in  size,  measuring  at  times  an  inch  or  more  in 
diameter.  They  are  spherical  or  flattened  tumors,  soft  and  elastic  to  the 
touch,  and  freely  movable  upon  the  subcutaneous  tissues. 

The  contents  may  be  a  white,  cheesy  matter  or  more  fluid,  and  of  an 
amber  or  brown  color.  Examined  mici'oscopically,  it  is  seen  to  be  com- 
posed of  epithelial  cells  which  have  undergone  a  more  or  less  complete 
granular  metamorphosis,  loose  granules,  compound  granular  corpuscles, 
cholesterine  crystals,  rudimentary  hairs,  etc.  The  wail  of  the  cyst  varies 
in  thickness,  being  at  times  very  thin  and  closely  adherent  to  the  sur- 
rounding structures,  and  at  others  thick  and  easily  detached.  Those 
upon  the  hairy  scalp,  commonly  known  as  "we?25,"  are  usually  filled 
with  an  amber- colored,  jelly-like  mass,  which  escapes  upon  section  or 
puncture  of  the  cyst.  Upon  the  face,  or  other  cutaneous  surface,  the 
contents  are  apt  to  be  cheesy  in  character. 

They  are  caused  by  cell-proliferation  and  the  accumulation  within  the 
hair-follicle  and  communicating  sebaceous  gland  of  its  normal  secretion, 
which  can  not  escape,  owing  to  the  partial  or  complete  occlusion  of  the 
excretory  duct.  Cataneous  cysts,  fi'om  direct  violence,  and  often  with- 
out any  appreciable  cause,  may  inflame  and  suppurate. 

Dermoid  cysts  are  closely  analogous  to  the  preceding,  although  situ- 
ated in  the  deeper  structures.  They  consist  of  a  limiting  membrane,  and 
liquid  and  solid  contents.  In  addition  to  the  changed  epithelial  cells  and 
granular  matter,  these  tumors  often  contain  tufts  of  hair,  rudimentary 


CYSTS— LIPOMA.  355 

teeth,  etc.  They  occupy  by  preference  the  ovary,  but  are  met  with  in 
all  parts  of  the  body. 

Mucous  cysts  are  usually  seen  upon  the  lips,  buccal  cavity,  vulva, 
and  anus.  They  may  occur  in  any  portion  of  the  alimentary  or  respira- 
tory passages,  or  in  any  of  the  cavities  lined  by  mucous  membrane.  The 
vrall  is  thin,  lined  with  epithelium,  and  adherent  to  the  surrounding- 
structures.  The  contents  are  a  viscid  mucus,  resembling  the  white  of  an 
egg.  The  cause  of  the  tumor  is  obstruction  of  the  normal  excretory 
duct.  The  character  of  the  tumor  may  be  suspected  from  the  location 
and  the  spherical  shape.  A  slight  puncture,  with  compression,  will  re- 
veal the  mucous  character  of  the  contents. 

Serous  Cysts. — Cysts  of  the  smaller  serous  cavities  may  result  from 
hypersecretion  of  the  normal  fluid  by  the  epithelia  lining  the  serous 
membrane,  in  which  the  excess  is  not  reabsorbed.  The  swellings  often 
observed  upon  the  back  of  the  wrist  and  hand,  and  sometimes  upon  the 
dorsal  aspect  of  the  foot,  are  typical  serous  cysts,  and  result  from  hyper- 
distention  of  normal  serous  bursse. 

Lipoma. — A  fatty  tumor  is  a  circumscribed  collection  of  adipose  tis- 
sue growing  independently  of  the  other  tissues.  Lipomata  usually  de- 
velop in  the  subcutaneous  cellular  tissue,  and  are  frequently  met  with 
about  the  back  of  the  neck  and  shoulders.  From  this  location  they  occa- 
sionally are  carried  by  gravity  toward  the  sacrum,  slipping  downward 
between  the  integument  and  deep  fascia.  Situated  superficially,  they 
grow  to  be  irregular  and  spherical  or  pyriform  tumors  of  varying  size  ; 
are  usually  single,  but  may  be  multiple.  Less  often  they  are  met  with 
in  the  glands,  muscles,  bones,  and  in  the  abdominal  viscera. 

Microscopically,  they  are  composed  of  vesicles  filled  with  oil  or  fat. 
The  vesicles  are  connective-tissue  corpuscles,  the  nuclei  of  which  are  dis- 
placed to  the  periphery  and  compressed  against  the  investing  membrane 
of  the  vesicle.  These  vesicles  are  held  together  in  clusters  of  various 
size  by  a  stroma  of  fibrous  tissue,  in  the  meshes  of  which  the  blood-vessels 
run.     The  whole  tumor  is  in  turn  encapsuled. 

Various  names  have  been  given  to  certain  complex  fatty  tumors; 
when  the  inter-vesicular  substance  is  myxomatous,  inyxo-lipoma ;  when 
the  connective  tissue  is,  e's.cesswQ,  fibro-lipoma  ;  in  bone,  osteo-lipoma ; 
when  very  vascular,  angeio-lipoma,  etc. 

Lipomata  may  undergo  granular  and  calcareous  metamorphosis,  and 
may  also  become  inflamed  and  break  down  as  a  very  offensive  and  slough- 
ing mass.  They  are  altogether  benign,  and  can  only  cause  death  by 
ulceration,  sepsis,  and  hjemorrhage,  or  by  pressure  upon  important  or- 
gans. 

The  diagnosis  depends  upon  the  soft,  uneven  feel  and  the  mobility  of 
the  mass.  It  is  only  to  be  differentiated  from  old  abscesses  or  cystic  tu- 
mors. If  the  history  does  not  point  to  the  diagnosis,  the  aspirator-needle 
will  be  of  service. 

The  treatment  is  removal  with  the  knife.  The  incision  may  be  straight 
for  a  small  tumor,  but  should  be  elliptical  for  large  growths,  in  order  to 
do  away  with  redundancy  after  the  tumor  is  turned  out.     The  capsule 


852  A  TEXT-BOOK   ON  SURGERY. 

should  be  opened,  and  tlie  tumor  may  be  turned  out  almost  wholly  with 
the  fingers. 

Fibroma. — This  variety  of  neoplasm  is  made  up  of  fibrous  tissue,  the 
filaments  of  which  are  at  times  arranged  in  bundles  which  run  in  all 
directions  ;  at  others,  there  is  little  or  no  fascicular  arrangement,  the  fila- 
ments being  entangled  in  all  directions.  In  the  interstices  of  the  bundles, 
or  between  the  fasciculi,  are  found  connective-tissue  cells,  the  poles  of 
which  communicate  with  each  other.  The  vascular  supply  is  limited. 
Fibromata  develop  chiefly  in  the  skin  and  subcutaneous  tissiies  and  peri- 
osteum, but  may  exist  in  any  other  portion  of  the  body.  They  are 
usually  single  and  small,  occasionally  multiple,  and  this  form  of  tumor 
may  attain  an  enormous  size.  In  shape,  those  developing  from  the  deeper 
tissues  are  spherical,  and  are  hard  to  the  touch.  In  theskin  they  are  often 
pedunculated  and  pyriform.  Fibromata  may  undergo  a  mucoid,  granular, 
or  calcareous  degeneration,  and  are  subject  to  inflammation  and  sujopu- 
ration,  as  are  other  neoplasms.  Not  possessing  a  high  degree  of  vascu- 
larity, the  danger  of  haemorrhage  is  not  great,  unless  a  rich  granulation- 
tissue  has  sprung  up  as  a  result  of  prolonged  irritation. 

Simple  fibroma  is  benign,  and  the  indications  in  ti-eatment  are  removal 
by  the  knife. 

Myxoma. — This  neoplasm  is  made  up  of  primitive  connective-tissue 
cells,  similar  to  those  observed  in  the  umbilical  cord  at  birth.  The  cell- 
elements  are  spherical  and  fusiform  in  shape.  The  former  are  isolated 
and  float  freely  in  the  gelatinous-like  intercellular  substance.  The  latter 
may  possess  two  or  more  poles,  and  anastomose  freely  with  each  other, 
forming  a  continuous  network  or  stroma  throughout  the  mass.  The 
vascular  sui3ply  is  rich.  These  neoplasms  occur,  as  a  rule,  in  the  skin 
and  subcutaneous  tissues  and  upon  the  mucous  surfaces,  especially  in 
the  nose  (mucous  or  soft  polypi).  They  may  develop,  however,  in  any 
portion  of  the  body,  and  have  been  observed  in  the  muscles,  bones,  and 
nerves,  the  mammary  gland,  kidney,  brain,  etc.  In  shape,  they  are 
usually  spherical,  of  small  size,  and  are  soft  and  doughy  to  the  touch, 
and  not  painful  unless  by  accident  the  sensory  nerves  are  pressed  upon 
by  the  tumor.  As  a  result  of  rupture  of  the  blood-vessels,  cysts  fre- 
quently occur  in  this  variety  of  neoplasm. 

The  treatment  is  early  and  complete  removal.  Pure  myxoma  does 
not  tend  to  recur  after  a  thorough  removal.  In  some  instances,  owing  to 
the  peculiar  location  of  the  neoplasm,  a  thorough  extirpation  is  impos- 
sible, and  in  these  cases  the  tumor  may  rapidly  recur.  The  cases  of  gen- 
eral metastasis  after  supposed  myxoma  were  probably  instances  in  which 
the  sarcomatous  nature  of  the  growth  had  been  overlooked. 

Myoma  is  a  tumor  composed  of  new -formed  muscular  elements. 
There  are  two  varieties,  namely,  those  composed  of  striated  or  voluntary, 
and  those  of  non-striated  or  involuntary  muscular  fibers. 

The  first  variety  are  extremely  rare,  and  are  of  less  clinical  importance 
than  the  non-striated  myoma. 

In  two  instances  the  striated  myoma  has  been  seen  in  a  congenital 
tumor  of  the  testicle,  and  in  a  few  other  instances  of  tumors  developed 


XEmOMA.  833 

wholly  or  in  part  in  the  embryo  or  foetus.  Dermoid  cysts  at  times  con- 
tain traces  of  striated  muscle. 

A  diagnosis  can  only  be  made  out  by  the  recognition,  under  the  mi- 
croscope, of  the  characteristic  striated  muscular  fiber.  The  j)rognosis  is 
favorable,  omng  to  the  benign  nature  of  the  tumor,  which,  nevertheless, 
should  be  removed  as  soon  as  recognized. 

In  the  non-striated  myoma  the  fusiform  elements  are  arranged  in  all 
directions,  either  in  bundles  or  groups  which  interlace,  or  there  may  be 
a  general  interlacing  of  the  separate  elements  without  fascicular  arrange- 
ment, as  in  many  of  the  organs  in  which  the  smooth  muscle  is  found. 
Between  these  bundles  true  connective-tissue  cells  exist,  and  in  these 
spaces  the  vessels  are  found.  The  nuclei  of  these  new-formed  elements, 
as  well  as  the  muscle-elements  proper,  do  not  differ  materially  from  the 
normal  non-striated  muscular  fibers. 

Non-striated  myomata  are  often  met  with  in  the  uterus.  In  many  of 
these  neoijlasms  there  is  a  variable  quantity  of  connective  tissue,  more  or 
less  organized,  and  for  this  reason  the  term  fibro-myoma  has  been  given 
to  these  tumors.  They  may  grow  from  the  waU  of  the  uterus,  toward  the 
peritonaeum  {extra-mural),  or  develop  in  the  substance  of  the  uterine 
muscle,  become  encapsuled  {inter-mural),  or  project  from  the  internal 
surface  into  the  cavity  of  this  organ  {sub-mucous  myoma,  intra-nnrral). 

This  variety  of  neoplasm  has  also  been  seen  in  various  other  localities, 
as  the  skin,  alimentary  canal  at  various  points,  the  prostate,  scrotum, 
etc.  The  diagnosis  depends  upon  the  recognition  of  the  characteristic 
fusiform  elements  under  the  microscope.  The  method  advocated  by 
Comil  and  Eanvier  is  to  macerate  the  sections  in  azotic  acid,  twenty  parts 
to  one  hundred  of  water,  or  caustic  potassa,  forty  parts  to  one  hundred 
of  water.  By  this  process  the  connective-tissue  stroma  is  dissolved  and 
the  muscular  elements  liberated. 

The  prognosis  in  this  form  of  myoma  is  favorable  as  far  as  recurrence 
is  concerned  when  the  removal  has  been  thorough.  They  not  infrequently 
produce  death,  either  directly  by  pressure  and  interference  with  the 
normal  functions  of  organs  necessary  to  life,  or  indirectly  by  causing 
hfemorrhage,  rendering  the  individual  more  likely  to  perish  from  some 
Intercurrent  affection. 

Treatment. — They  should  be  removed,  when  this  can  be  done  with  a 
justifiable  degree  of  safety. 

Neuroma. — A  tumor  composed  of  new-formed  nerve-tissue  is  rarely 
met  with.  Many  so-called  neuromata  are  connective-tissue  neoplasms 
springing  from  the  neurilemma.  They  may  be  made  up  of  nerve-cells  or 
nerve-fibers  (Fig.  769). 

The  former  are  even  rarer  than  the  latter.  Small  particles  of  gray 
matter  have  been  seen  in  dermoid  cysts,  and  in  a  few  instances  neo- 
plasms of  this  variety  have  been  seen  in  the  brain  and  spinal  cord. 

Fascicular  neuromata  may  occur  in  the  nerves.  They  exist  as  slight 
elliptical  swellings  or  enlargements  of  the  nei-ve  involved,  may  be  single, 
or  there  may  be  a  succession  of  nodosities  in  the  course  of  the  nerve. 

The  symptoms,  in  addition  to  the  tumor,  which  may  at  times  be  made 


854 


A  TEXT-BOOK  ON  SURGERY. 


nrr  i[i'i}\\ lllil'iil// 


/ 


769, — Neuromata  developed  in  the  divided 
nerve-tissues  after  amputation  of  tlie  member. 
(After  Cornil  and  Eanvier.) 


out  by  palpation,  are  those  of  pain  or  interference  with  the  function  of 
the  pari  involved.  A  careful  analysis  with  the  microscope  alone  can 
determine  an  accui-ate  diagnosis. 

The  prognosis  is  not  grave,  in 
so  far  as  the  life  of  the  j)atient  is 
concerned,  but  the  removal  of  the 
neoplasm  may  of  necessity  involve 
an  injury  of  the  trunk  in  or  upon 
which  it  is  located,  and  in  this 
manner  may  add  an  element  of 
gravity  to  the  result.  They  should 
be  extirpated,  and,  where  (as  will 
almost  always  be  the  case)  the  posi- 
tively benign  character  of  the  neo- 
plasm is  not  evident,  a  section  of 
the  nerve  below  and  above  the  tu- 
mor, as  well  as  a  portion  of  the 
surrounding  tissues,  should  be  re- 
moved. 

Angioma. — The  angiomata  are 
tumors  of  new-formed  vessels,  cap- 
illaries, arterioles,  or.  veins.     They 

are  frequently  congenital,  and  may  also  appear  at  any  period  after  birth. 
Microscopically,  the  simple  forms  are  made  up  of  'capillaries,  arte- 
rioles, and  veinules  in  plexuses  richer  than  the  normal,  and  held  to- 
gether by  a  connective- tissue  stroma  of 
varying  thickness.  In  the  more  formi- 
dable tumors — cavernous  ncBvi — the  ves- 
sels are  larger,  with  thickened  walls  of 
dense  connective  tissue,  and  at  times  a 
quantity  of  non-striated  muscular  fibers. 
The  vasa  vasorum  are  also  met  with  in 
the  walls  of  the  sinuses. 

The  former  variety  appear  as  red  or 
bluish  spots  or  stains  in  the  skin,  of 
various  sizes  and  shapes,  at  times  rising 
above  the  level  of  the  integument. 

The  method  of  treatment  is  fully 
described  in  the  chapter  upon  diseases 
of  the  vascular  system. 

Lymphangioma. — Tumors  composed 
of  new-formed  lymphatic  vessels  are 
very  rarely  met  with.  In  their  construction  they  do  not  materially 
differ  from  the  angiomata.  The  new  tissue  consists  of  a,  capillary  net- 
work of  lymph-channels,  in  arrangement  analogoiis  to  the  capillary  ves- 
sels in  the  smaller  angiomata. 

In  the  case  shown  in  Fig.  771,  I  removed  by  dissection  a  plexus  of 
lymphatic  vessels  about  as  large  as  a  hen's  egg.     The  walls  were  saccu- 


Fia.  T70. — Angioma  (cirsoid  aneurism)  of  the 
temporal  region. 


CHONDROMA. 


855 


lated,  and  the  vessels  were  distended  with  clear  lymph.     In  other  in- 
stances the  lymph-canals  have  a  cavernous  arrangement  comparable  to 
the  structure  of  the  cavernous 
ngevus  described  in  the  article 
on  vascular  tumors. 

LympTiadenoma  has  been 
given  under  the  heading  of 
Malignant  Neoplasms.  Many 
forms  of  enlargement  of  the 
lymphatic  glands  are  not  true 
tumors,  since  they  are  not  com- 
posed of  new-made  gland- tis- 
sue, are  due  to  cancerous  inlil- 
tration,  to  tubercle,  to  syphi- 
litic adenitis,  tubercular  de- 
posit, etc.  Tubercular  lympho- 
mata  should  always  be  extir- 
pated when  tuberculosis  of  the 
deeper  organs  can  be  excluded, 
provided  that  the  operation  of 
removal  does  not  involve  a  too 
great  risk  of  life.  The  removal 
of  enlarged  glands  from  metas- 
tasis in  cancer  should  also  be  done  when  there  is  a  reasonable  hope 
of  cutting  ofE  the  disease  from  the  centers. 

Chondroma. — New  formations  of  cartilage  develop  in  and  from  the 
connective-tissue  cells  of  any  portions  of  the  body,  excepting  from  car- 


FiG.  771. — Lymphangioma  of  left  buccal  wall. 


Fig.  772.— Diffuse  chondroma  of  the  phalanges  and  metacarpal  bones.     (After  N^laton.) 

tilage  proper.  The  bones  and  periosteum  are  favorite  points  of  origin 
for  these  neoplasms.  Developing  from  within  the  bone,  a  cartilaginous 
new  formation  is  termed  an  encJiondroma ;  if  from  the  periosteum,  a 


856  A  TEXT-BOOK   ON   SURGERY. 

•pericliondroma.  Quite  a  number  of  cliondromata  have  been  observed 
in  the  testicles  and  in  the  parotid  glands.  They  may  assume  all  sorts 
of  shapes,  growing  into  more  or  less  si)hei'ical  tumors,  or  the  new  tissue 
may  be  generally  diffused  in  the  normal  tissue. 

In  the  bones  of  the  hand  and  fingers  they  give  rise  to  marked  de- 
formities and  to  considerable  pain,  from  displacement  of  the  normal 
structures,  and  interference  with  nutrition  (Fig.  772). 

The  new  formation  of  cartilage  is  preceded  by  an  iniiammatory  pro- 
cess varying  in  intensity,  usually  of  a  mild  nature,  yet  resulting  in  the 
proliferation  of  the  cells  of  the  part  involved,  and  the  formation  of  an 
embryonic  tissue  from  which  the  cartilage  is  formed,  as  in  the  normal 
development  of  this  tissue.  Some  of  these  cells  become  the  cartilage- 
cells  proper,  and  are  collected  in  groups  of  different  sizes,  while  others 
form  a  connective-tissue  stroma  around  the  collections  of  cartilage- cells. 
The  vessels  find  their  way  along  these  bundles  of  connective  tissue. 

The  proportion  of  connective-tissue  stroma  varies  in  different  tumors. 
When  the  cartilage-cells  and  groups  are  plentiful,  with  a  limited  quan- 
tity of  intervening  fibrous  tissue,  the  mass  is  strictly  a  chondroma. 
When  the  stroma  preponderates,  it  is  termed  a  fibro-chondroma.  In 
certain  forms  of  these  tumors  there  is  a  paucity  of  connective-tissue  fibers 
as  well  as  cartilage-cells,  although  both  are  present  in  quantity  sufiicient 
for  recognition.  The  mass  of  tissue  may  be  embryonic,  and,  under  such 
conditions,  the  tumor'  may  be  sarcomatous  in  character.  Simple  chon- 
droma is  benign,  but  a  mixed  chondroma  of  an  embryonic-tissue  type 
must  be  classed  with  the  malignant  neoplasms. 

Chondromata  may  undergo  fatty  or  granular  degeneration,  may  ossify 
in  part,  may  become  infiltrated  with  calcareous  matter,  or  undergo  the 
mucoid  change. 

Treatment. — Removal  is  indicated  when  pain  is  unbearable,  or  when 
the  sarcomatous  nature  of  the  neoplasm  is  evident. 

Osteoma. — Tumors  of  new-formed  bone-tissue  may  develop  from  the 
normal  bone  and  periosteum,  or  in  the  tissues  removed  from  the  bones. 
There  are  three  varieties — the  eburnated,  compact,  and  spongy. 

In  the  first,  or  ivory-like  neoplasms,  the  bone  is  exceedingly  dense 
and  hard,  and  contains  bone-corpuscles  and  canaliculi  which,  though 
well  marked,  are  more  irregular  in  arrangement  than  in  normal  forms. 
This  new-formed  bone-tissue,  however,  does  not  possess  blood-vessels. 
These  tumors  are  especially  apt  to  be  observed  upon  the  bones  of  the 
skull,  notably  those  of  the  frontal  and  parietal  regions. 

The  compact  or  spongy  neoplasms  are  in  structure  analogous  to  the 
normal  compact  or  spongy  bone-substance.  In  the  latter  the  bony  frame- 
work is  light,  and  the  medullary  si^aces  larger  than  normal. 

An  osteoma  formed  upon  the  outside  of  an  old  bone  is  called  an  exos- 
tosis ;  developed  within  the  medullary  space,  an  enostosis. 

Exostoses  grow  as  more  or  less  well-rounded  tumors  beneath  the  peri- 
osteum, or  as  sharp  spikes  or  thorns  projecting  out  from  the  bone.  Such 
spines  are  in  the  great  majority  of  instances  directed  upward  (stalag- 
mites) in  the  axis  of  the  tendon  in  and  about  which  they  develop.     In 


OSTEOMA.  857 

rare  instances  the  direction  is  downward,  as  seen  in  the  stalactite 
(Fig.  307). 

Bony  neoplasms  may  also  develop  in  any  of  the  cartilaginous  tissues 
of  the  body,  and  this  change  is  usually  one  of  senility.  Beyond  this, 
bone  may  form  in  the  muscles,  choroid,  the  serous  membranes  in  all 
locations,  and  in  the  integument. 

Osteomata  are  always  benign.  If  dangerous  at  all,  it  is  from  com- 
pression of  important  organs.  Those  developed  from  the  internal  sur- 
face of  the  cranial  bones  and  along  the  vertebral  canal  are  especially 
dangerous  in  this  respect. 

Treatment. — Interference  is  not  called  for,  unless  pressure  upon  im- 
portant organs  renders  it  necessary. 


IITDEX. 


Abbe.  Intestinal  anastomosis,  529 ;  rings  for, 
546,  548,  note. 

Abdomen,  586 ;  abscess,  579,  586 ;  affections  of, 
525;  bandage  for,  17;  contusions,  586;  gun- 
shot injuries,  587 ;  wounds,  586,  587. 

Abdominal  aorta,  aneurism  of,  204, 228 ;  ligation 
of,  264;  in  iliac  aneurism,  229;  section,  545, 
589. 

Abscess,  63 ;  abdominal,  579 ;  acute,  63  ;  after 
caries,  63;  alveolar,  471 ;  ano-reotal,  596 ;  aspi- 
ration of,  63,  64 ;  circumscribed,  63 ;  chronic, 
63;  cold,  62,  63,66;  diagnosis  of,  63,  204;  dif- 
fused, 63  ;  membrane,  61,  63 ;  metastatic,  66 ; 
of  antrum  of  Highmore,  471 ;  of  cornea,  411 ; 
of  frontal  sinus,  884,  445  ;  of  groin,  diagnosis, 
557 ;  of  jaw,  470 ;  of  joints,  63  ;  of  kidney,  620 ; 
of  liver,  582 ;  of  mammary  gland,  515 ;  of 
neck,  492 ;  of  ovary,  773 ;  of  parotid  gland, 
470;  of  scalp,  383;  of  spine,  63;  of  spleen, 
585 ;  of  testicle,  746 ;  of  thoracic  wall,  521 ; 
of  thyroid  gland,  494 :  of  tongue,  483 ;  of  ton- 
sils, 489 ;  of  ventricles  of  the  brain,  394 ;  of 
vulva,  751 ;  perirectal,  596 ;  perityphlitic,  580 ; 
retroperitoneal,  581 ;  retropharyngeal,  492, 507, 
790 ;  spinal,  789 ;  subacute,  63 ;  wall,  61,  63. 

Absorbable  animal  di-ains,  8. 

Absorbent  dressings  for  wounds,  9. 

Acceleration  of  blood-current  in  inflammation, 
54. 

Accidental  amputation,  107. 

Accommodation,  425. 

Acetabulum,  fracture  of,  307. 

Acetate  of  lead,  in  prostatorrhcea,  673 ;  of  zinc, 
in  gonorrhoea,  681,  685. 

Acid,  boric,  3 ;  cotton,  9 ;  for  surgery  of  the  eye, 
397;  carbolic,  3,  5;  for  angeioma,  198;  near 
eye,  397;  for  haemorrhoids,  617;  for  wounds, 
74;  in  erysipelas,  89;  solution,  3,  5;  chromic, 
for  catgut,  2 ;  nitric,  in  hospital  gangrene, 
105 ;  in  phagedenic  ulcers,  716 ;  oxalic,  for 
sponges,  7 ;  salicylic,  3, 5  ;  salicylico-boric,  solu- 
tion, 5. 

Aconite,  in  erysipelas,  87;  in  inflammation,  60; 
in  tonsillitis,  489 ;  in  urethral  chills,  693. 


Acromion  process,  fracture  of,  294. 

Active  ulcer,  99. 

Actual  cautery  as  a  hasmostatic,  73. 

Acupressure,  73. 

Acupuncture  for  treatment  of  aneurism,  211. 

Acute  gangrene,  100. 

Adams.     Osteotomy  of  femur,  802. 

Adenitis,  164;  acute,  164;  axillary,  in  affections 
of  mammary  gland,  519 ;  cervical,  492,  494 ; 
inguinal,  684,  715  ;  syphilitic,  719,  722. 

Adenoma,  849 ;  of  intestine,  586 ;  of  kidney,  624 ; 
of  lip,  455  ;  of  mamma,  515 ;  of  testicle,  748. 

Adeno-sarcoma,  847. 

Adhesions  of  intestine,  535 ;  of  labia,  752 ;  of 
prepuce,  712. 

Adhesive  plaster,  in  wounds,  76. 

Administration  of  chloroform,  34 ;  of  ether,  26 ; 
per  rectum,  82. 

Advancement  of  insertion  of  eye-muscles,  426. 

After-treatment  of  patients  after  operation,  53. 

Agnew.     Anthrax,  83 ;  canalicula-knife,  406. 

Air-tumor  of  scalp,  383. 

Aitkin.    Bilharzia  hismatobia,  645. 

Albumen  in  the  urine,  642. 

Alcohol  as  an  antiseptic  solution,  3 ;  for  cat- 
gut, 2. 

Alcoholism,  cause  of  arteritis,  173. 

Alexander.     Case  of  aneurism,  228. 

Alimentary  canal,  obstruction  of,  530;  rupture 
of,  587. 

Alligator-forceps,  503,  701. 

AUingham.     Ulcer  of  rectum,  600. 

A  His.     Brain  surgery,  393  ;  ether-inhaler,  27. 

Alternating  tonics  in  hospital  gangrene,  105, 

Amaurosis,  424. 

Amblyopia,  424. 

Am  Ende.    Sponges,  7 ;  sublimate  gauze,  9. 

Ametropia,  426. 

Ammonlo-magnesian  calculus,  646. 

Amputation,  107;  at  ankle-johit,  139,  141;  at 
ealcaneo-astragaloid  joint,  139  ;  at  carpo-raeta- 
carpal  joint,  124 ;  at  carpo-radial  joint,  126  ;  at 
elbow-joint,  153,  158;  at  hip-joint,  154;  at 
knee-joint,  148 ;  at  radio-carpal  joint,  126, 127 ; 


860 


A  TEXT-BOOK   ON  SURGERY. 


at  shoulder- joint,  133;  at  tarso -  metatarsal 
joint,  136  ;  at  tibio-tarsal  joint,  143 ;  by  circu- 
lar skin-flaps,  116, 129 ;  by  circular  solid  flaps, 
110 ;  by  double  crescentic  flaps,  117 ;  by  double 
rectangular  flaps,  118;  by  mixed  flaps,  118; 
by  modified  circular  flaps,  117;  by  oblique 
solid  flaps,  115,  116;  by  oval  flaps,  117;  con- 
tinuous irrigation  for,  119;  for  malignant  tu- 
mors, 846;  in  dislocations,  324;  knives,  35; 
medio-tarsal,  189  ;  methods  of,  109  et  seq. ;  of 
Bruns,  145  ;  of  Garden,  151 ;  of  Chopart,  139  ; 
of  Dupuytren,  134 ;  of  Esmarch,  127  ;  of 
Forbes,  139;  of  Gritti,  152;  of  Gunther,  145; 
of  Hancock,  140 ;  of  Hey,  137 ;  of  Larrey,  134 ; 
of  Lee,  148 ;  of  Le  Fort,  143 ;  of  Lignerol,  139 ; 
of  Lisfrane,  137 ;  of  Malgaigne,  139 ;  of  Mason. 
Erskine,  154 ;  of  Pirogofif,  143 ;  of  Sedillot,  148 ; 
of  Smith,  Stephen,  141  (Syme),  146  (leg).  150 
(knee);  of  Syme,  139,  141;  of  Teale,  147;  of 
Texton,  139 ;  of  arm,  130 ;  of  breast,  519 ;  of 
cervix  uteri,  764 ;  of  clavicle,  134 ;  of  fingers, 
120 ;  of  foot,  141,  145 ;  of  fore-arm,  127 ;  of 
hand,  130 ;  of  index-finger,  123 ;  of  leg,  146 ; 
of  little  finger,  134  ;  of  middle  finger,  123 ;  of 
mammaiy  gland,  519 ;  of  penis,  709 ;  of  pre- 
puce, 711 ;  of  ring-finger,  123 ;  of  scapula,  134 ; 
of  superior  extremity,  130;  of  tarsal  bones, 
138  ;  of  tarsus,  135  ;  of  thigh,  152 ;  of  thumb, 
121,  133 ;  of  toes,  184 ;  open  method  of  treat- 
ing, 118;  special  amputations,  120  et  seq.; 
tibio-tarsal,  141. 

Amussat.     Colostomy,  577. 

Amylaceous  bodies  in  prostate,  675. 

Amyloid  degeneration  of  viscera,  790. 

AnEesthesia,  22 ;  by  the  rectum,  36  ;  death  from, 
33;  general,  34;  local,  22;  of  male  urethra, 
689. 

Anaesthetics,  32 ;  chloroform,  25,  33 ;  cocaine, 
22 ;  ether,  34,  35,  36  ;  ice,  34  ;  rhigolene,  34. 

Anandale.     Case  of  aneurism,  310. 

Anatomical  forceps,  43. 

Anatomical  relations  of  the  arteries  of  lower  ex- 
tremity, 365-373;  arteries  of  neck,  236-340, 
249-253 ;  arteries  of  upper  extremity,  bones  of 
carpus,  368  (longitudinal  section) ;  bones  of 
foot,  138,  830 ;  large  vessels  of  aorta,  254,  355 ; 
muscles  of  lower  extremity,  149-160  (trans- 
verse sections);  muscles  of  upper  extremity, 
138-133  (transverse  sections) ;  organs  of  female 
pelvis,  753,  753;  organs  of  male  pelvis,  551, 
553,  554;  organs  of  thoracic  and  abdominal 
cavities,  337 ;  parts  in  the  surgical  triangles  of 
neck,  343;  parts  of  elbow,  378  (longitudinal 
section);  parts  of  foot,  375  (longitudinal  sec- 
tion) ;  parts  of  groin,  555,  567 ;  parts  of  hand, 
380  (longitudinal  section) ;  parts  of  head,  394 
(anterior-posterior  section) ;  parts  of  hip-joint, 
370  (longitudinal  section) ;  parts  of  knee-joint, 
311  (longitudinal  section) ;  parts  of  perinaium, 
663 ;  parts  of  shoulder- joint,  377  (longitudinal 


section);  parts  of  urethra,  689  (longitudinal 
section) ;  parts  of  vulva,  751 ;  parts  of  perito- 
nteum  and  bladder,  631 ;  rectum  and  anus,  591, 
593 ;  tunica  vaginalis  and  peritonieum,  736,  737. 

Anastomosis  of  intestine,  529-546. 

Anchylosis  of  elbow,  827 ;  of  hip,  803 ;  of  knee, 
809 ;  of  lower  jaw,  476 ;  of  shoulder,  826. 

Anderton.  Case  of  aneurism  of  both  vertebral 
arteries,  238. 

AneFs  method  of  treating  aneurism,  207,  209 : 
syringe,  407. 

Aneurism,  179,  202 ;  after  wounds,  304 ;  anasto- 
motic, 195  ;  arterio-venous,  333 ;  aspiration  of, 
204 ;  by  anastomosis,  195 ;  cirsoid,  190 ;  diag- 
nosis of,  197,  204 ;  diffuse,  203,  204 ;  dissecting, 
202,  204;  false,  304;  fibrillated  fibrin  in,  203; 
fusiform,  308  ;  needle,  3 ;  of  abdominal  aorta, 
304,  338 ;  of  aorta,  204 ;  of  arch  of  aorta,  211 ; 
of  axillary  artery,  322,  334,  336;  of  brachial 
artery,  337;  of  carotid,  212;  of  common  ca- 
rotid, 230 ;  of  common  iliac  artery,  339 ;  of  de- 
scending aorta,  313 ;  of  external  iliac  artery, 
339 ;  of  femoral  artery,  230 ;  of  gluteal  artery, 
330;  of  iliac  artery,  304,  339;  of  innominate 
artery,  304,  213,  316  ;  of  peroneal  artery,  331 ; 
of  popliteal  artery,  331 ;  of  profunda  femoris, 
231;  of  radial  artery,  337;  of  sciatic  artery, 
230;  of  subclavian  artery,  223;  of  thyroid 
.gland,  494 ;  of  thoracic  aorta,  211 ;  of  tibial 
artery,  231 ;  of  ulnar  artery,  227;  of  vertebral 
artery,  238 ;  pressure  of,  on  cesophagus,  509 ; 
prognosis  of,  204,  205;  sacculated,  203,  311; 
special  forms  of,  211 ;  spherical,  302 ;  symptoms 
of,  304 ;  treatment  of,  305 ;  by  acupuncture, 
311 ;  by  Anel's  method,  207,  209  ;  by  Antyllus's 
method,  307 ;  by  Brasdor's  method,  307,  309 ; 
by  compression,  307 ;  by  compression  with  in- 
struments, 388 ;  by  compression  with  the  fin- 
ger, 307 ;  by  foi-ced  flexion,  310 ;  by  galvano- 
puncture,  310 ;  by  Hunter's  method,  207,  209 ; 
by  injection,  306,  311;  by  massage,  210;  by 
Tufnell's  method,  206,  227;  by  Valsalva's 
method,  307 ;  by  Wardrop's  method,  307,  209 ; 
true,  302 ;  varicose,  332  ;  varieties  of,  302. 

Aneurismal  varix,  303,  383. 

Angelo's  method  of  bleaching  sponges,  7. 

Angio-liporaa,  851. 

Angioma,  195,  854 ;  cutaneous,  195 ;  diffuse,  197; 
encapsulated,  197 ;  near  the  eye,  397 ;  of  ear, 
438;  of  intestine,  536;  of  kidney,  634;  of 
larynx,  506 ;  of  lower  jaw,  474 ;  of  mammary 
gland,  513;  of  nipple,  518;  of  scrotum,  734; 
plexiform,  195. 

Animal  ligatures  in  aneurism,  309 ;  poisons  pro- 
ducing inflammation,  54. 

Ankle-joint,  amputation  at,  189, 141 ;  dislocation 
of,  848;  exsection  of,  374;  osteo-arthritis  of, 
365. 

Anterio-posterior  curvature  of  the  spine,  786. 

Anterior  tibial  artery,  ligation  of,  273. 


INDEX 


861 


Anthrax,  83 ;  bacillus  of,  83. 

Antifebrin  in  inflammation,  60. 

Antipyrin  in  dissection  wounds,  84 ;  in  erysipelas, 
87;  in  inflammation,  60;  in  urethral  chills, 
694. 

Antiseptic  dressings,  permanent,  application  of, 
54;  solutions,  etc.,  3,  4. 

Antrum  of  Highmore,  abscess  of,  471 ;  drainage 
of,  471 ;  operative  invasion  of,  473 ;  trephining 
of,  289. 

Antyllus.    Aneurism,  method  of  treatment,  207. 

Anus,  absence  of,  591 ;  artificial,  formation  of, 
593 ;  atresia,  591 ;  cancer,  605  ;  eczema,  594 ; 
erythema,  594 ;  fissure,  594,  599 ;  fistule,  595 ; 
neoplasms  of,  605;  neuralgia,  608;  pityriasis 
versicolor,  594;  prolapse,  608;  pruritus,  593; 
stricture.  601,  603;  ulceration,  600. 

Aorta,  abdominal,  aneurism  of,  204,  338;  ligation 
of,  364 :  for  iliac  aneurism,  239 ;  aneurism  of, 
211;  compression  of,  for  wounds,  73;  of  the 
ox,  as  ligature,  1. 

Aphasia,  operation  for,  391. 

Aponeurosis,  palmar,  contraction  of,  830. 

Apparatus  for  cyphosis,  796;  for  holding  liga- 
tures, 3;  for  exstrophy  of  bladder,  638;  for 
fracture  of  lower  jaw,  291 ;  for  knock-knee, 
807;  for  talipes  equinus,  811;  for  torticollis, 
780 ;  for  transfusion,  78. 

Arch  of  aorta,  aneurism  of,  203,  211 ;  aneurism 
of  transverse,  212. 

Arcus  senilis,  412. 

Arendt.  Case  of  aneurism,  ligation  of  innomi- 
nate artery,  333. 

Arm,  amputation  of,  130 ;  bandage  for  the,  14 

Arrest  of  circulation,  a  cause  of  gangrene, 
100. 

Arsenic  in  furuncle,  95. 

Arterial  compression  in  wounds,  73  ei  seq. 

Arterial  cutaneous  tumor.  190,  195 ;  cirsoid  tu- 
mor, 190;  embolism,  188;  occlusion  in  gan- 
grene, 101 ;  thrombosis,  188,  189  ;  tumor,  190 ; 
varix,  190. 

Arteries,  calcification  of,  177,  179;  ligation  of, 
during  operation,  51 ;  surgical  operations  upon, 
334  et  seq. 

Arterio-venous  aneurism,  232. 

Arteritis,  171;  acute,  172;  deformans,  179;  idio- 
pathic, 177;  non-traumatic,  177;  pathogeny  of, 
172:  pathological  anatomy  of,  184;  rheumatic, 
187;  sequels  of,  173;  syphilitic,  181, 187;  trau- 
matic, 173,  173;  treatment  of,  187. 

Artery,  compression  of  Uiac,  154. 

Artery,  Ligation  and  statistics  of  anterior  tibial, 
273 ;  of  aorta,  264 ;  of  ascending  pharyngeal, 
250 :  of  axillary,  259 ;  of  brachial,  261 :  of  caro- 
tid, common,  2-37;  external,  244;  internal,  243; 
of  dorsalis  pedis,  274;  of  facial,  250 ;  of  femoral, 
269;  of  gluteal,  367;  of  iliac,  common,  364; 
external,  366,  368;  internal,  266;  of  innomi- 
nate, 236 ;  of  intercostal,  262 ;  of  internal  mam- 


mary, 255,  259 ;  of  internal  maxillary,  253  ;  of 
internal  pudic,  267 ;  of  lingual,  248 :  of  occipi- 
tal, 250;  of  popliteal,  271 ;  of  posterior  auricu- 
lar, 252 ;  of  posterior  scapular,  256 ;  of  poste- 
rior tibial,  272 ;  of  profunda  femoris,  271 ;  of 
radial,  363;  of  sciatic,  267;  of  subclavian,  253, 
256,  258 ;  of  superior  intercostal,  256 ;  of  su- 
perior thyi-oid,  348 ;  of  suprascapular,  356  ;  of 
temporal,  353;  of  thyroid  axis,  355,  359;  of 
transversa  colli,  255 ;  of  ulnar,  262 ;  of  verte- 
bral, 255,  259. 

Arthritis,  351 ;  tuberculous,  353. 

Articulations,  surgery  of  the,  325. 

Artificial  anus,  539,  569;  respiration  in  ether 
narcosis,  30. 

Ascarides  in  the  rectum,  595. 

Aspergillus  in  the  auditory  canal,  440. 

Aspermatism,  674. 

Asphyxia,  artificial  respiration  in,  31. 

Aspiration  of  abscess,  63,  64;  of  abscess  of  ab- 
domen, 579 ;  of  abscess  of  gall-bladder,  585 ; 
of  abscess  of  liver,  585 ;  of  abscess  of  neck,  493 ; 
of  abscess  of  spina  bifida,  800;  of  abscess  of 
tongue,  483 ;  of  aneurism,  304 ;  of  ankle-joint, 
365;  of  bladder,  637;  of  joints  for  synovitis, 
353 ;  of  kidney,  635 ;  of  knee-joint,  363 ;  of 
knee-joint  for  patellar  fracture,  315 ;  of  pleural 
cavity,  532  ;  of  shoulder-joint,  367. 

Aspirator,  65 ;  for  transfusion,  78 ;  in  ether  nar- 
cosis, 39 ;  Tiemann  &  Go's.,  637. 

Assistants,  distribution  of,  during  operation,  50, 
110. 

Asthenopia,  428. 

Astigmatism.  426,  427,  430. 

Astragalus,  dislocations  of,  349 ;  diagnosis,  348 ; 
exsection  of,  376. 

Atheroma,  173,  177,  178. 

Atheromatous  degeneration  of  arteries,  a  cause 
of  gangrene,  103. 

Athletes,  prone  to  arteritis,  175. 

Atresia  ani,  591 ;  recti,  591. 

Atropine,  for  ophthalmoscopic  examination,  428 ; 
in  iritis,  415. 

Atrophy  of  the  optic  nerve,  437;  of  the  tongue, 
483. 

Attrition  due  to  aneurism,  204. 

Auchinclos.     Case  of  aneurism,  224. 

Auditory  canal,  accumulations  of  cerumen  in, 
439;  aspergillus  in,  440;  furuncles  of,  439; 
foreign  bodies  in,  438:  fungous  growths  in, 
440 ;  neoplasms  in,  439  ;  polypus  of,  439. 

Auricle,  adhesions,  438;  cartilaginous  tumors, 
438 ;  drooping,  438 ;  hypertrophy,  438  ;  instru- 
ments, 438  ;  speciila,  489  ;  wounds,  438. 

Auricular  artery,  posterior,  ligation  of,  252. 

Auvert.  Case  of  aneurism.  Ligation  of  subcla- 
vian artery,  334. 

Ayers.   Case  of  ligation  of  subclavian  artery.  257. 

Axillary  artery,  aneurism,  222,  226  ;  ligation, 
259. 


862 


A  TEXT-BOOK   ON  SURGERY. 


Bacillus  of  blue  pus,  63 ;  of  glanders,  83  ;  of 
tetanus,  83 ;  saprogenes,  60. 

Bacteria  in  inflammation,  60. 

Balanitis,  678,  683. 

Balano-posthitis,  679,  683. 

Bandage,  elastic,  41 ;  figure-of-eight,  13 ;  four- 
tailed,  30;  handkerchief,  30;  in  inflammation, 
57;  knotted,  19  ;  Martin's,  99  ;  methods  of  ap- 
plying, 11 ;  plaster-of -Paris,  10  ;  reverse,  13  ! 
roller,  10;  spica,  17;  spiral,  11. 
•  Bandages  for  the  abdomen,  17 ;  for  the  arm,  14 ; 
for  the  axilla,  15 ;  for  the  breast,  17 ;  for  the 
chin,  18,  290 ;  for  the  eye,  30 ;  for  the  face,  20 ; 
for  the  fingers,  13 ;  for  the  fore-arm,  14 ;  for 
the  foot,  15 ;  for  the  hand,  13 ;  for  the  head, 
18;  for  the  hip,  16;  for  the  knee,  17;  for  the 
leg,  16;  for  the  lower  extremity,  16;  for  the 
shoulder,  14 ;  for  the  thigh,  16  ;  for  the  thorax, 
17;  for  the  toes,  15  ;  for  the  upper  extremity, 
14 ;  for  ulcers,  99  ;  for  varix,  200. 

Bands,  constricting  the  intestine,  535. 

Banks,  E.  A.  Dilating  filiform  bougies,  693 ; 
urethrotome,  691. 

Barlow.  Cases  of  aneurism,  315,  216,  217;  opera- 
tion for  vascular  tumor,  193,  194;  syphilitic 
arteritis,  188, 187. 

Bartholow.  Action  of  quinine  on  septic  germs, 
171. 

Barton's  fracture,  301. 

Barwell.  Cases  of  aneurism,  ligation  of  carotid 
and  subclavian  arteries,  315,  317,  319 ;  club- 
foot, operation  for,  815 ;  operation  for  vascular 
tumors,  193,  194. 

Basedow's  disease,  497. 

Basilar  artery,  occlusion  of,  183. 

Base  of  skull,  fractures  of,  384. 

Basin,  pus-,  48. 

Battey,  Dupuytren's  contraction,  831. 

Bavarian  splints,  303. 

Bayer.  Case  of  aneurism,  ligation  of  subclavian, 
334. 

Beall.     Hernia  cerebri,  385. 

Bee-stings,  81. 

Beer's  keratome,  417. 

Belladonna  in  lymphadenitis,  164. 

Bell.    Illustration  of  tetanus,  88. 

Berger.     Cirsoid  tumor,  191,  198. 

Bickersteth.  Case  of  aneurism,  ligation  of  in- 
nominate, 319,  233. 

Biesiadeeki.     Syphilitic  arteritis,  181. 

Bifid  spine,  799. 

Bigelow.  Dislocation  of  hip,  341,  843,  344 ;  lith- 
otrity,  651. 

Bilateral  lithotomy,  663. 

Bilharzia  hjematobia,  682,  645. 

Biliary  calculi  in  intestines,  531. 

Billroth.  Adeno-sarcoma,  847 ;  cavernous  tu- 
mors, 196 ;  excision  of  tongue,  487;  varix,  199. 

Binz.  Action  of  quinia  on  emigrant  corpuscles, 
171. 


Bischoffi.     Transfusion,  78. 

Bisector,  663. 

Bistouries,  35. 

Blackman.  Ligation  of  carotid  for  vascular  tu- 
mors, 193. 

Black  wash,  716. 

Bland.     Case  of  aneurism,  218. 

Bladder,  affections  of  the,  637;  aspiration  of, 
637;  carcinoma,  640;  drainage  of,  630,  638; 
exstrophy,  627 ;  foreign  bodies  in,  645,  665 ; 
gunshot-wounds,  639 ;  hernia,  639 ;  hypertro- 
phy, 632  ;  inflammation,  633  ;  papilloma,  639  ; 
paralysis,  634 ;  parasites,  632 ;  puncture  of, 
suprapubic,  637 ;  through  rectum,  688  ;  rupt- 
ure, 680  ;  stone  in,  645  ;  tumors,  639  ;  wounds, 
639. 

Blasius.    Cheiloplasty,  464. 

Bleaching  sponges,  7. 

Blepharitis,  399. 

Blepharo-phiraosis,  399. 

Blepharoptosis,  400. 

Blepharospasm,  399,  409. 

Blisters,  in  inflammation,  60. 

Blizzard.     Lithotomy-knife,  36. 

Blood,  in  the  urine,  643 ;  transfusion,  77. 

Bloodless  method  in  amputations,  107. 

Blood-letting,  in  inflammation,  57. 

Blue  pus,  63. 

Boil,  97;  of  perinaBum,  758;  of  vulva,  751. 

Boiled  water  for  wounds,  74. 

Boiling  as  a  disinfectant,  3. 

Bone-drains,  8 ;  drills,  38,  373 ;  forceps,  38 ;  in- 
struments, 37 ;  metastatic  abscess  in,  67 ;  plates, 
absorbable,  539  ;  tumors,  vide  tumors. 

Bones,  surgery  of,  375 ;  of  the  tarsus,  dislocations 
of  the,  850. 

Boracic  acid,  3 ;  in  surgery  of  the  eye,  397. 

Borated  cotton,  9. 

Bothrop,  79. 

Bosworth.  Cocaine,  action  of,  on  blood-vessels, 
443. 

Bow-legs,  809. 

Bougie,  Banks's,  695 ;  bulbous,  689 ;  dilating  fili- 
form, 695;  flexible,  699;  gum  filiform,  696; 
oesophageal,  509 ;  Otis's,  689 ;  oval-tipped,  689 ; 
rectal,  603;  silk,  686;  urethral,  699;  whale- 
bone, 696. 

Brachial  artery,  aneurism  of,  327;  ligation  of, 
201. 

Brain,  abscess  of,  388;  compression,  284;  con- 
cussion, 385 ;  gunshot-wounds,  286 ;  hernia  of, 
885 ;  symptoms  of  injury  to,  389 ;  syphilis,  723  ; 
wounds,  893. 

Brasdor's  method  of  operating  for  aneurism,  207. 

Braune.    Frozen  sections,  127 ;  vide  anatomical. 

Breast,  vide  mammary  gland,  abscess  of,  515; 
amputation  of,  519 ;  bandage,  17. 

Breschet.     Cirsoid  aneurism,  191. 

Briddon.     Double  tourniquet,  208. 

Broad-jawed  forceps,  41,  53. 


INDEX. 


863 


Broad  ligament,  cyst  of,  775. 

Broca.  Case  of  innominate  aneurism,  218 ;  in- 
jections into  vascular  tumors,  193. 

Bromines  in  hospital  gangrene,  105. 

Bronchi,  foreign  bodies  in,  501. 

Bronchocele,  493, 

Brown.     Case  of  aneurism,  231. 

Bruit  in  aneurism,  305,  211. 

Bruns.  Amputation  of  foot,  145;  cheiloplasty, 
465. 

Bryant.  Arteritis  rheumatioa,  187;  cases  of 
aneurism,  ligation  of  carotid  and  subclavian, 
216,  218;  hernia  in  females,  550;  phlebites, 
168,  169;  phlebolites,  200;  pyfemia,  67;  test 
for  dislocation  of  femur,  801 ;  test  for  fracture 
of  neck  of  femur,  309 ;  varix,  198. 

BubnofE.  Ligation  of  arteries,  process  of  occlu- 
sion after,  189. 

Bubo,  diagnosis,  557 ;  gonorrhcEal,  684 ;  inguinal, 
715;  phagedenic,  715;  syphilitic,  719. 

Buchanan.     Excision  of  vascular  tumors,  193. 

Buchu,  in  suppression  of  urine,  625. 

Buck's  method  of  extension,  307,  309 :  for  dislo- 
cations of  knee-joint,  348  ;  for  fracture  of 
thigh,  307 ;  for  osteotomy  of  femur,  802 ;  rec- 
tum trocar,  638. 

Buds,  vascular,  forming  capillaries  in  wounds, 
69. 

Bufo  vulgaris,  venom  of,  80. 

Bull.  Case  of  aneurism,  ligation  of  innominate 
artery,  223. 

Bullen.    Case  of  ligature  of  subclavian,  257. 

Bullet-probe,  Nelaton's,  43. 

Bunions,  824. 

Burns,  93. 

Burrows.    Cheiloplasty,  462. 

Busch.    Excision  of  vascular  tumors,  193. 

Bursitis  of  shoulder,  366. 

Butcher.  Case  of  aneurism,  ligation  of  carotid 
and  subclavian,  218. 

Butlin.     Epithelioma  of  tongue,  484. 

Buzzard.    Syphilitic  arteritis,  183,  187. 

Cabine"",,  operating,  44,  47. 

Csesarean  section,  766. 

Calcaneo-astragaloid  disarticulation,  139. 

Calcaneum,  amputation,  139. 

Calcaneus,  talipes,  813. 

Calcareous  degeneration  of  arteries,  177,  179; 

degeneration  of  thyroid  gland,  495 ;  deposit  in 

veins,  199. 
Calcification  of  arteries,  177,  179. 
Calcium  sulphide  in  furuncle,  97 ;  in  hordeolum, 

399. 
Calculous  concretions  of  the  gall-bladder,  584; 

of  the  prostate,  675 ;  of  the  tonsils,  490. 
Calculus,  biliary,  531 ;  in  the  bladder,  645 ;  in  the 

prostate.  675 ;  in  tlie  renal  pelvis,  622 :  in  the 

ureter,  621;   mulberry,  622;   renal,  620,  632, 

626,  646. 


Callaway.  Diagnosis  of  dislocation  of  humerus, 
338,  331. 

Callender.    Hyperdistention  of  abscess,  64. 

Callisen.     Colostomy,  576. 

Callus,  382  ;  pin-callus,  283. 

Calomel  after  hysterectomy,  765;  in  inflamma- 
tion, 60 ;  in  ulcers  of  penis,  716. 

Campbell.     Case  of  aneurism,  316. 

Canal,  auditory,  vide  auditory. 

Canaliculus  lachrymalis,  obstruction  of,  406. 

Canalization  of  cells  to  form  capillaries  in 
wounds,  69. 

Cancer,  838;  vide  also  epithelioma  and  carci- 
noma. 

Cannabis  Indica  for  rabies,  82 ;  in  tetanus,  90. 

Canthoplasty,  409. 

Canula  for  thyrotomy,  498. 

Capillaries,  formation  of,  in  inflammation,  69 ; 
in  wounds,  69. 

Capillary  cutaneous  tumors,  195 ;  hemorrhage  in 
wounds,  how  controlled,  74;  thrombosis  the 
cause  of  furuncle,  97,  98. 

Carbolic  acid  as  an  antiseptic,  3 ;  for  angeioma, 
195 ;  in  haemorrhoids,  injection  of,  616. 

Carbolized  gauze,  9. 

Carbuncle,  97,  98 ;  of  lip,  445. 

Carcinoma,  838,  vide  also  epithelioma;  of  antnim 
of  Highmore,  471 ;  of  the  anus,  605 ;  of  the 
bladder,  640;  of  the  breast,  518;  of  the  intes- 
tine, 536 ;  of  the  kidney,  624 ;  of  the  larynx, 
506 ;  of  the  liver,  583 ;  of  the  mamma,  518 ; 
of  the  meninges,  385;  of  the  oesophagus,  511 ; 
of  the  ovary,  775 ;  of  the  parotid  gland,  468 ; 
of  the  penis,  707 ;  of  the  prostate,  674 ;  of  the 
testicle,  749 ;  of  the  thyroid  gland,  494,  497 ; 
of  the  tongue,  483 ;  of  the  tonsil,  490 ;  of  the 
urethra,  706. 

Carden.    Amputation  at  the  knee,  151. 

Caries,  275;  of  the  jaw,  470;  of  the  spine,  787; 
of  the  teeth,  471 ;  of  the  vertebrje,  492. 

Carotid,  common,  213 ;  aneurism  of,  230 ;  diag- 
nosis, 228 ;  ligation  of,  237 ;  statistics  of,  243 ; 
for  aortic  aneurism,  213,  333 ;  external,  Uga- 
tion  of,  244 ;  internal,  ligation  of,  242. 

Carpal  bones,  dislocation  of,  337 ;  excision,  379 ; 
fractures,  304. 

Carpo-radial  joint,  disarticulation  of,  126. 

Cartilages,  laryngeal,  fractures  of,  292. 

Cartilaginous  tumors  of  the  ear,  488. 

Case,  Dr.  Meigs,  suspension  carriage,  798,  801. 

Casts  in  the  urine,  644. 

Castration,  749. 

Cataract,  418. 

Cat-bite,  81. 

Catgut,  as  ligatures  and  sutures,  1 ;  chromic,  as 
ligature,  2 ;  as  drainage,  8  ;  ligature  in  aneu- 
rism, 210;  in  wounds,  73. 

Catgut-rings,  Abbe's,  529. 

Catheter,  double-current,  634,  687 ;  French,  636 ; 
gum,  633 ;  Nelaton,  633 ;  silk,  63G. 


864 


A  TEXT-BOOK  ON  SURGERY. 


Catheterization,  636. 

Cautery,  actual,  in  rabies,  83 ;  for  arterial  varix, 
190 ;  in  hospital  gangrene,  105 ;  in  inflamma- 
tion, 60  ;  in  phagedenic  ulcer,  716. 

Cavernous  bodies,  fracture  of,  707. 

Cells,  proliferation  of,  in  fractures,  281 ;  in  in- 
flammation, 55 ;  in  ostitis,  379 ;  in  S3'philis, 
736 ;  in  wounds,  68. 

Cellulitis,  diffuse,  86 ;  pelvic,  630. 

Centipede,  venom  of,  81. 

Cerebral  localization,  390. 

Cerumen,  impaction  of.  in  auditory  canal,  439. 

Cervix  uteri,  amputation  of,  764;  excision  of, 
764;  lacerations,  763. 

Chalazion,  399. 

Chamberlain.     Ligation  of  axillary  artery,  360. 

Championniere.  Localization  of  cerebral  symp- 
toms. 389  ;  of  Rolando's  fissure,  391. 

Chancre,  717 ;  of  the  anus,  600  ;  of  the  rectum, 
600,  601 ;  of  the  vulva,  757. 

Chancroid  of  penis,  713,  714 ;  of  rectum,  600 ;  of 
vulva,  757. 

Changes,  tissue,  in  inflammation,  55  ;  in  wounds, 
68. 

Charcot.     Localization  of  brain  symptoms,  389. 

Cheek,  moles  of,  455  ;  nsevus,  455  ;  plastic  oper- 
ations, 465. 

Cheiloplasty,  463,  463. 

Chelius.     Aneurismal  varix,  193. 

Chest,  foreign  bodies,  524 ;  gunshot-wounds  of, 
533;  injuries  of,  533;  wounds,  523. 

Chevalier.    Vascular  tumors,  194. 

Chiene.     Operation  for  genu  valgum,  807. 

Chin,  bandage,  31. 

Chisels,  38. 

Chloral  hydrate  in  rabies,  83 ;  in  tetanus,  90. 

Chloride  of  iron  in  aneurism,  206  ;  in  erysipelas, 
87. 

Chloride  of  zinc  as  an  antiseptic,  3,  5. 

Chloroform  as  an  anfesthetic,  25, 33  ;  advantages 
of,  over  ether,  35  ;  death  from,  34  ;  death-rate 
of,  35 ;  in  rabies,  83 ;  in  tetanus,  90 ;  test  for 
purity  of,  34. 

Cholecystotomy,  584. 

Cholesteatoma,  848. 

Cholesterin  crystals  in  pus,  63. 

Chondritis,  504. 

Chondroma,  855  ;  of  the  finger,  834. 

Chopart's  amputation  through  the  tarsus,  139. 

Chordee,  678 ;  treatment  of,  680. 

Choroiditis,  416,  437. 

Chromic  acid,  as  an  escharotic  in  the  larynx,  506  ; 
catgut,  3. 

Cicatrization  in  wounds,  70. 

Circular  skin  flaps  in  amputations,  110. 

Circumcision,  711  ;  cocaine  anaesthesia  for,  34. 

Circumflex  nerve,  injury  to,  in  dislocation  of 
humerus,  333. 

Cirrhosis  of  ovary,  773. 

Cirsoid  arterial  tumor,  190. 


Citrate  of  potash  after  lithotrity,  654 ;  calculus, 
623 ;  for  hematuria,  645 ;  for  renal  calculus, 
623 ;  for  urethritis,  680 ;  in  cystitis,  633. 

Clamp  for  haemorrhoids,  616 ;  of  Dupuytren,  570 ; 
scrotal,  743. 

Clavicle,  absence  of,  826 ;  amputation,  134 ;  dis- 
locations, 326;  excision,  134,  533;  fractures, 
292 ;  ostitis.  533. 

Cleanliness,  personal,  49. 

Cleansing  the  hands  before  operations,  49;  of 
gunshot-wounds,  73 ;  of  parts  in  amputations, 
109  ;  of  wounds,  73. 

Cleft  palate,  478,  481 ;  operation  for,  23 ;  instru- 
ments for,  35. 

Clover's  inhaler,  28. 

Club-foot,  810. 

Club-hand,  838. 

Coagulation  in  inflammation,  55 ;  in  veins,  167, 
168 ;  in  wounds,  68 ;  necrosis  in  arteritis,  179, 
180. 

Cobra  venom,  78,  79. 

Cocaine  amesthesia,  32  ;  for  catheterization,  636 ; 
for  incision  of  bubo,  685 ;  for  incision  of  fu- 
runcles, 97;  for  opening  of  abscesses,  64;  in 
abdominal  section,  588 ;  in  anal  fissure,  599 ; 
in  anal  fistula,  597 ;  in  aspiration  of  gall-blad- 
der, 584;  in  conjunctivitis,  407;  in  exploration 
of  urethra,  689 ;  in  extraction  of  cataract,  430 ; 
in  extraction  of  teeth,  477;  in  fasciotomy  of 
hand,  831;  in  haemorrhoids,  612,  617;  in  in- 
complete lithotrity,  654 ;  in  keratitis,  413 ;  in 
laryngeal  operations,  506 ;  in  ligation  of  varix, 
200 ;  in  operation  for  cleft  palate,  478 ;  for 
hydrocele,  739 ;  for  ingrowing  toe-nail,  825 ; 
for  varicocele,  741 ;  in  operations  on  tendons 
of  fingers,  832 ;  in  phalangeal  amputations, 
131 ;  in  phlegmon  of  finger,  835 ;  in  pruritus 
ani,  594 ;  in  removing  moles,  201 ;  in  the  sur- 
gery of  external  ear,  438  ;  in  tonsillotomy,  490 ; 
in  urethrotomy,  692,  693 ;  in  venesection,  57 ; 
suppositories  in  anal  affections,  603. 

Coccyx,  dislocations,  608 ;  fracture,  306 ;  neural- 
gia, 608. 

Cod-liver  oil  in  furuncle,  97 ;  in  morbus  coxarius, 
360. 

Cohnheim.  Calcification  of  arteries,  180;  cell 
proliferation  in  inflammation,  55;  emigrant 
corpuscles,  171. 

Cold  abscess,  63,  63,  66. 

Cold,  action  of,  on  animal  tissues,  97;  as  an 
auKsthetic,  34 ;  as  a  haemostatic,  73 ;  in  inflam- 
mation, 58 ;  in  lymphangitis,  163 ;  in  tetanus, 
90 ;  in  wounds,  73. 

Cold  water  in  burns,  93. 

Colic,  renal,  630,  633. 

Collapse  in  burns,  93. 

Colles.  Case  of  aneurism,  ligation  of  subclavian, 
234;  harelip,  460;  fracture  of  radius,  301; 
transmissibility  of  syphilis,  732. 

Colloid  carcinoma,  839 ;  cysts,  850. 


IXDEX. 


865- 


Colon,  exsection  of,  546. 

Color-blindness,  424. 

Colostomy,  537,  5T6,  593. 

Colpo-cvstotomv,  761. 

Columnar  epithelioma,  842. 

Common  carotid,  aneurism  of,  220 ;  ligation  of, 
237;  statistics  of,  243. 

Common  iliac  artery,  aneurism  of,  229 ;  ligation 
of,  264. 

Compound  fractures,  280,  284;  of  leg,  321;  of 
pateUa,  318. 

Compress,  umbrella,  662. 

Compression  in  inflammation,  58;  instrumental, 
in  aneuiism,  206 ;  in  synoTitis,  352 ;  of  ankle, 
365;  in  vascular  tumors,  193;  of  the  brain, 
284,  387. 

Concretions,  calcareous,  in  Terns,  199  ;  intestinal, 
531 ;  in  the  prostate,  675 ;  of  the  gall-bladder, 
584. 

Concussion  of  the  brain,  285 :  diagnosis  from 

.  compression,  285. 

Condylomata,  syphilitic,  720. 

Congenital  adhesions  of  prepuce,  712;  hernia, 
565 ;  hydrocele,  736. 

Conjunctiva,  anaesthesia  of,  by  cocaine,  22. 

Conjunctivitis,  croupous,  409  :  diphtheritic,  410  ; 
f olUeular,  407 ;  granular,  408. 

Conoidal  projectiles,  90. 

Constant  irrigation.  7 ;  in  inflammation,  59. 

Constriction  of  arteries  in  inflammation,  58 ;  of 
intestines,  535 ;  of  limbs  for  internal  hsemor- 

.  rhage,  77 ;  of  vessels  in  inflammation,  55 ;  of 
vessels  in  wounds,  70. 

Contagion  of  anthrax,  83. 

Contagiousness  of  hospital  gangrene,  104. 

Continuity  and  contiguity,  terms  used  in  ampu- 
tations, 107. 

Continuous  compression,  for  aneurism,  206 ;  su- 
ture, 75. 

Contraction  of  the  hand  due  to  paralysis,  8.30; 
of  the  mouth,  446 ;  of  the  palmar  fascia,  830. 

Contreconp,  284. 

Control  of  haemorrhage  from  wounds,  71 ;  in  op- 
erations on  the  tongue,  486. 

Contused  wounds,  68. 

Contusions  of  the  abdominal  walls,  586 ;  of  the 
face,  396:  of  the  kidney,  619;  of  the  scrotum,  734. 

Cooper.  Case  of  aneurism  (ligation  of  aorta),  223. 
239 ;  ligation  of  innominate,  235 ;  treatment 
of  dislocation  of  elbow.  336. 

Coote.     Vascular  tumors,  197. 

Copaiba  balsam  in  gonorrhoea,  682. 

Copperhead,  venom  of,  79. 

Copper,  sulphate  of,  for  conjunctivitis,  408. 

Coracoid  process,  fracture  of,  294. 

Cord,  spermatic,  affections  of,  744 ;  hydrocele  of, 
735. 

Comeitis,  412. 

ComU  and  Kenvier.  Angioma,  formation  of, 
196 ;  arterial  ligation,  189 ;  arteries,  histology 


of,  172:  arteritis,  179  ;  syphilitic,  183;  cavern- 
ous tumors,  196;  classification  of  tumors, 
837;  giant-cells  in  sarcoma,  844;  induration 
and  hypertrophy  of  glands,  839;  metastasis, 
839;  ostitis,  277;  permanent  occlusion  of  ar- 
teries, 189 ;  pathology'  of  tumors,  837 ;  phlebi- 
tis, 165,  167,  168;  spinal  tuberculosis,  787; 
structure  of  arteries,  172;  varix,  197,  199; 
veins,  histology,  165. 

Coming.     Cocaine  anaesthesia,  2-3. 

Corns,  824,  849. 

Coronoid  process,  fractures  ot-  300. 

Corpora  cavernosa,  fracture  of,  707. 

Corpuscle,  compound  granular,  62. 

Corrosive  sublinSate  as  an  antiseptic,  3. 

Cotton,  absorbent  borated,  9. 

Cotton-batting  in  gangrene,  102,  103. 

Cotton,  styptic,  73. 

Counter-irritants  in  inflammation,  60. 

Cradle.  Reeves's  suspensory,  799 ;  swinging,  for 
elevation,  57. 

Cramps,  a  symptom  of  gan-rrene,  103. 

Cranium,  fracture,  284. 

Creoline  as  an  antiseptic,  3,  4,  76-5. 

Crepitus  in  fracture,  280. 

Crinoline  bandages,  10. 

Critchet,  iridectomy,  414. 

Crosby.  Aneurism,  treatment  of,  208 ;  disloca- 
tion of  the  hip,  treatment  of,  343;  fracture 
bed,  -307. 

Cross-suture,  76. 

Crotalus,  76. 

Croup,  laryngeal  tubes  in,  499 ;  tracheotomy  in, 
499. 

Croupmus  conjunctivitis,  409. 

Crushing  of  stone  in  the  bladder,  650. 

Cruveiihier,  arterial  varix,  190;  case  of  ligation 
of  subclavian  and  carotid,  2-37 ;  phlebolites, 
200. 

Crystalline  lens,  418. 

Cuboid  bone,  amputation  of,  146. 

Cuneiform  bones,  amputation  of,  146. 

Cupped  sound,  673. 

Curette,  urethral,  701. 

Curvature,  anterior,  of  the  spine.  786 ;  lateral,  of 
the  spine,  cervical,  779 ;  dorsal,  782 ;  posterior, 
of  the  spine,  787. 

Cutaneous,  angioma,  195;  arterial  tumor,  195; 
capQlary  tumor,  195 ;  vascular  tumors,  190 ; 
venous  tumors,  195. 

CycUtis,  416. 

Cylinder-celled  epithelioma,  842. 

Cyphosis,  78. 

Cyst.  830 ;  hydatic,  vide  hydatid :  of  antrum  of 
Highmore,  471 ;  of  broad  ligament,  774,  775  ; 
of  conjunctiva,  410  ;  of  kidney,  623  ;  of  larynx, 
506  ;  of  lip.  455  :  of  lower  jaw.  474;  of  mam- 
mary  gland,  51 7 ;  of  neck,  493 ;  of  nipple, 
513 ;  of  ovary,  774 ;  of  pancreas,  .386 ;  diagno- 
sis, 622 ;  of  scalp,  382 ;  sebaceous,  383  ;  seronSj 


«66 


A  TEXT-BOOK  ON  SURGERY. 


386 ;  of  scrotum,  734 ;  of  spleen,  586 ;  diag- 
nosis, 623 ;  of  testicle,  748,  749 :  of  thyroid 
body,  494  ;  of  tongue,  483 ;  of  tonsil,  490  ;  of 
vesiculse  serainales,  744. 

Cystadenoma  of  ovary,  774. 

Cystic  degeneration  of  ovary,  771 ;  dilatation  of 
lymphatic  vessels,  165  ;  polypus  of  rectum, 
607. 

Cysticercus  of  the  tongue,  483. 

Cystine  calculus,  647. 

Cystitis,  632  ;  cause  of  pyelitis,  620. 

Cystocele,  629,  760. 

Cystoma  of  parotid  gland,  468. 

Cystoscope,  640. 

Cystotomy,  654 ;  of  gall-bladder,  586 ;  perineal, 
630,  638,  658 ;  supra-pubic,  654. 

Czerny-Lembert  suture,  528,  542. 

Dacryo-adenitis,  406. 
Daoryo-cystitis,  406. 
Dacryoliths,  406.  443. 
Dactylitis,  syphilitic,  726.  • 
Daniel.     Curette,  411 ;  spoon,  421. 
Davidson.    Syphilitic  arteritis,  183,  187. 
Davis.    Spinal  brace,  791. 

Davy.    Treatment  of  external  iliac  aneurism, 230. 
Dawbarn.     Exseetion  of  intestine,  569. 
Death-rate  in  amputations,  107 ;  in  tetanus,  89. 
Dephamps.    Aneurism,  209. 
Deformities,  779. 

Deformity  of  the  femur,  804 ;  of  the  fingers,  839, 

834;  of  the  hand,  828;  of  the  knee,  804;  of 

the  lower  extremity,  801 ;  of  the  spine,  779 ; 

of  the  toes,  822 ;  of  the  upper  extremity,  836. 

Degeneration  of  arteries,  177,  179;  of  thyroid 

gland,  495  ;  of  ovaries,  cystic,  771. 
De  Lacerda.     Serpent-wounds,  treatment  of,  80. 
Deligation,  vide  ligation :  of  arteries,  vide  artery ; 
cause  of  arteritis,  173;  for  angeioma,  197;  for 
cutaneous  vascular  tumors,  192 ;  occlusion  of 
arteries  by.  188. 
Delpech.     Ligation  of  axillary  artery,  260. 
Demarkation,  line  of,  in  gangrene,  101. 
Demarquai.   Injections  for  vascular  tumors,  193. 
Demarre.     Retractors,  411. 
Denis.    Coagulation  of  blood,  167. 
Dennis.    Emphysema  of  abdominal  cavity,  .587; 

open  method  of  treating  amputations,  119. 
Deposits,  urinary,  641. 
Depression  of  cranial  bones  in  fractures  of  the 

skull,  284. 
Dermatitis,  84,  163. 
Dermoid  cysts,  850 ;  of  the  mamma,  517 ;  of  the 

ovary,  774. 
Dermoplasty,  94. 

Destruction  of  skin  by  acids,  etc.,  97. 
Detachment  of  retina,  424. 
Deviation  of  nasal  septum,  445. 
Diabetes  mellitus,  643. 
Diachylon  plaster  for  ulcers,  99 ;  in  burns,  94, 


Diaphragmatic  hernia,  555 ;  treatment,  573. 
Diarrhoea  in  hospital  gangrene,  105. 
Dick.    Gum  bougie,  689. 
Didot.     Operation  for  web-finger,  830. 
Dieffenbach.     Amputation  of  hip,  155 ;  rhino- 
plasty, 448. 
Digital  compression  in  aneurism,  207. 
Digitalis  for  aneurism,  206. 
Diffuse  aneurism,  203,  304. 
Diphtheria,  laryngeal  tube  for,  499 ;  tracheotomy 

in,  499. 
Diphtheritic  conjunctivitis,  410. 
Dilatation  of  preputial  orifice,  711,  713 ;  of  ves- 
sels in  arteritis,  179;  in  inflammation,  55;  of 
urethral  stricture,  692. 
Diplopia,  433. 

Direct  pressure,  for  aneurism,  208. 
Director,  grooved,  43. 

Disarticulation  at  astragalus,  139 ;  at  calcaneus, 
139;  at  carpo- metacarpal  joint,  124;  at  carpo- 
radial  joint,  126 ;  at  hip,  153 ;  at  knee,  148 ; 
at  metatarsal  joint,  136 ;  at  shoulder,  131, 133 ; 
at  tarso-metatarsal  joint,  135 ;  at  tibio-tarsal 
joint,  143 ;  of  finger-phalanges,  131 ;  of  toes, 
135. 
Discission  for  cataract,  432. 
Diseases  of  the  joints,  351. 
Disinfection  in  hospital  gangrene,  106 ;  of  hands 

in  amputations,  110;  of  instruments,  3. 
Dislocations,  325 ;  complicated,  325 ;  compound, 
335 ;  congenital,  325 ;  diagnosis,  325 ;  partial, 
325;  pathological  anatomy  of,  333 ;  pathologi- 
cal, 340 ;  primitive,  325 ;  prognosis  of,  346  ; 
secondary,  325 ;  traumatic,  325,  340. 
Dislocation  of  the  ankle,  348;  backward,  349; 
compound,  349;  forward,  349;  inward,  348; 
outward,  348;  of  the  astragalus,  349;  of  the 
clavicle,  326 ;  of  the  elbow,  324 ;  of  the  fibula, 
at  ankle,  348,  349 ;  of  the  fingers,  338 ;  of  the 
foot,  348 ;  of  the  hand.  337 ;  of  the  hip-joint, 
338;  congenital,  340:  diagnosis,  340;  iliac, 
340,  344;  pubic,  339,  345 ;  reduction,  342; 
with  pulleys,  344 ;  sciatic,  340 ;  statistics,  339 ; 
thyroid,  341,  344 ;  of  the  humerus,  327 ;  sub- 
acromial, 333;  subcoracoid,  337;  subclavicu- 
lar, 337,  330  ;  subglenoid,  330  ;  subspinous, 
333 ;  of  the  jaw,  325 ;  of  the  knee,  346 ;  of  the 
lower  jaw,  335;  of  the  metacarpo-phalangeal 
joints,  338 ;  of  the  patella,  348 ;  of  the  phalan- 
ges, 338 ;  of  the  radial  head  (subluxation),  334 ; 
of  the  radius  and  ulna  at  elbow,  324;  of  the 
ribs,  350;  of  the  shoulder,  327;  subacromial, 
333 ;  subcoracoid,  337 ;  of  the  spine,  atlo- 
axoid,  350 ;  occipito-atloid,  350 ;  of  the  tarsal 
joints,  3.50 ;  of  the  tarsus,  350 ;  of  the  thigh, 
338;  of  the  tibia,  347;  of  the  vertebrse,  350; 
of  the  wrist,  337. 
Displacements  of  abdominal  organs,  586. 
Dissecting  aneurism,  202,  204. 
Dissection  wounds,  84. 


INDEX. 


867 


Distal  ligature  for  aneurism  of  aorta,  213. 

Distribution  of  assistants  and  nurses  during  op- 
eration, 50. 

Diverticulum  of  intestines,  535 ;  of  oesophagus, 
512. 

Division  of  urethral  stricture,  692. 

Divulsion  of  anus,  599 ;  of  prepuce,  713 ;  of  ure- 
thral stricture,  692. 

Dobbel's  solution,  444. 

Dog-bite,  81. 

Dorsalis  pedis  artery,  ligation  of,  274. 

Double  crescentic  flap,  117;  rectangular  flap, 
118. 

Double-current  catheter,  634,  687. 

Double-knot,  52. 

Double-needle  suture,  76. 

Drainage  of  bladder,  630,  638 ;  of  skull,  394 ;  in 
amputations,  109,  114;  in  carbuncle,  99;  in 
fracture  of  skull,  394;  in  gunshot-wounds, 
74;  in  osteomyelitis,  278;  in  suppuration  of 
knee,  364;  in  wounds,  74;  tubes,  7. 

Drains,  bone,  7. 

Dressings,  1 ;  apparatus  used  in,  1 ;  application 
of,  after  operations,  53;  after  amputations, 
114,  115;  permanent,  53. 

Dressing-scissors,  42. 

Drilling  for  drainage  of  antrum  of  Highmore, 
471 ;  the  trochanter  in  morbus  cosarius,  362. 

Drills,  bone-,  38,  372. 

Dropsy,  abdominal,  diagnosis,  622. 

Drum  for  testing  edge  of  instruments,  417. 

Dry  gangrene,  103. 

Duct  of  Steno,  affections  of,  466. 

Dugas.    Dislocation  of  humerus,  328,  331. 

Dunglison.    Phlebolites,  200. 

Duodenostomy,  530. 

Duodenum,  operations  on,  530. 

Dupuytren.  Case  of  aneurism,  220 ;  contraction 
of  palmar  fascia,  830  ;  operation  for  strangu- 
lated intestine,  570 ;  method  of  amputation  at 
shoulder-joint,  134. 

Dura  mater,  carcinoma  of,  385 ;  sarcoma  of,  385. 

Durante.  Permanent  occlusion  of  arteries  after 
deligation,  189. 

Dutoit.     Case  of  aneurism,  227. 

Ear,  adhesions,  438 ;  cartilaginous  tumors,  438 ; 
diseases  and  injuries,  438 ;  drooping,  438  ;  hy- 
pertrophy, 438 ;  instruments  for,  438 ;  specula 
for  examining,  439 ;  wounds,  438. 

Eburnated  osteoma,  856 ;  ostitis,  276. 

Ecchymoraa,  195. 

Ecchinococci,  vide  hydatid. 

!6craseur,  in  ablation  of  the  tongue,  486. 

Ectropion,  401. 

Eczema  of  the  anus,  594 ;  of  the  eyelids,  405 ;  of 
the  nipple,  513  ;  of  the  scrotum,  734.     . 

Edison.     Electric  illumination,  44. 

Effusion,  serous,  into  sheath  of  cord,  735 ;  into 
tunica  vaginalis,  735 ;  of  joint,  vide  synovitis. 


Elastic  bandage,  Esmarch's,  41 ;  fiber  in  veins, 
165,  166 ;  ligature,  41 ;  for  fistula  ani,  598 ; 
silk  for  varix,  200. 

Elbow-joint,  amputation  at  the,  128 ;  anchylosis, 
827;  disarticulation,  334;  dislocation  at  the, 
334 ;  essection,  377 ;  synovitis,  367. 

Electric  arc  in  suprapubic  cystotomy,  655. 

Elephantiasis,  200;  nevoid,  196;  of  the  head, 
383 ;  of  the  scrotum,  734. 

Elevation  as  a  haemostatic  in  wounds,  73 ;  in  ery- 
sipelas, 86;  in  gangrene,  102;  in  inflamma- 
tion, 57 ;  in  phlebitis,  171 ;  of  parts  of  skull, 
391. 

Elliot.  Case  of  aneurism,  of  innominate  artery, 
217. 

Emboli,  167. 

Embolism,  arterial,  188 ;  fatty,  283. 

Embryonic  tissue  in  inflammation,  56 ;  in 
wounds,  69. 

Emergency  tourniquet,  72. 

Emigration  of  leucocytes  in  inflammation,  55. 

Emmet.  Cervix-scissors,  763 ;  needles,  43 ;  pe- 
rinaeorrhaphy,  757. 

Emmetropia,  426. 

Emphysema  of  abdominal  cavity,  587 ;  subcuta- 
neous, in  gangrene,  101. 

Emprosthotonos  in  tetanus,  89. 

Empyema,  553 ;  diagnosis,  583 ;  irrigation  of,  4, 
523. 

Encephalocele,  385. 

Eneephaloid,  839 ;  of  mammary  gland,  518 ;  of 
rectum,  605. 

Enchondroma,  856 ;  of  ear,  438 ;  of  larynx,  506  ; 
of  lower  jaw,  474;  of  mamma,  516;  of  parotid 
gland,  468 ;  of  tongue,  483  ;  of  testicle,  748. 

Endarteritis,  171,  175;  obliterans,  174;  syphi- 
litic, 723,  724. 

Endocarditis  rheumatica,  187. 

Endophlebitis,  165. 

Endostitis,  275. 

Enostosis,  856. 

Ensor.  Case  of  aneurism,  of  the  innominate  ar- 
tery, 217. 

Enterocele,  551. 

Enterolithes,  531. 

Enterostomy,  537. 

Entropion,  404. 

Enucleation  of  eye,  416 ;  of  tumor  of  mamma, 
520. 

Eosine-test-gauze,  9. 

Epicanthus,  405. 

Epicystotomy,  654,  657,  664. 

Epididymitis,  744;  chronic,  737;  gonorrhceal, 
683 ;  tuberculous,  747. 

Epilepsy,  operation  for,  393. 

Epiphora,  405. 

Epiploeele,  551. 

Epispadias,  705. 

Epistaxis,  442. 

Epithelia  in  the  urine,  643. 


868 


A  TEXT-BOOK   ON  SURGERY. 


Epithelioma,  839,  840 ;.  of  the  anus,  605 ;  of  the 
bladder,  640;  of  the  breast,  519;  of  the  intes- 
tine, 536 ;  of  the  larynx,  506  ;  of  the  lip,  453  ; 
of  the  mammary  gland,  519;  of   the  nipple, 
518;  of  the  nose,  444;  of  the  oesophagus,  511 ; 
of  the  penis,   707 ;  of  the  rectum,  536,  605 ; 
of  the  scrotum,  483 ;  of  the  vulva,  757. 
Equinia,  82. 
Equinus,  talipes,  811. 
Erectile  tumors,  195. 

Erichsen.     Exarticulation  of  phalanges,  131. 
Ergot  as  a  hajmostatic,  71 ;  for  aneurism,  206, 
211 ;  for  angeioraa,  197  ;  for  hjematuria,  645  ; 
in  abdominal   hemorrhage  after  rupture  of 
organs,  587. 
Erysipelas,  84,  86, 163  ;  dressings  in,  87 ;  isolation 
in,  86:  local  treatment,  86;  of  scrotum,  734; 
phlegmonous,    86 ;    precautions    against,   87 ; 
prophylaxis,  86. 
Erythema,  85,  163 ;  anal,  86  ;  gyratum,  80 ;  iris, 

86 ;  nodosum,  86 ;  of  anus,  594. 
Escape  of  leucocytes  from  blood-vessels  in  in- 
flammation, 55. 
Escharotic,  for  angeioma,  197. 
Eserine  in  extraction  of  cataract,  431. 
Esmarch's  bandage    during   irrigation,   3  ;   for 
aneurism,  208 ;  for  wounds,  73 ;    in  amputa- 
tions, 108 ;  chloroform  apparatus,  33 ;  method 
of  curing  angeioma,  197 ;  of  exarticulation  at 
shoulder-joint,  134;  at  carpo-metacarpal  Joint, 
,  124 ;  of   exarticulation  of  phalanges,  181 ;  of 

treating  aneurism,  309. 
Esophoria,  433. 

Ether,   administration  of,  by   the  rectum,    36; 
inhalation  of,  25  ;  inhaler,  38  ;  in  the  reducing 
of    fractures ;  284 ;   solution  of  iodoform  in, 
5 ;  spasm  of  glottis  in  inhalation  of,  29  ;  spray, 
for  local  anisesthesia,  24. 
Evacuation  of  abscess,  64;   of  gas  from  intes- 
tine, 538  ;  of  liver,  583. 
Evans.     Aneurism  of  innominate  artery,  216. 
Eversion  of  the  bladder,  637. 
Examination  of  urine,  641. 

Excision  of  astragalus,  376 ;  of  branches  of  fifth 
nerve,  473 ;  of  cervix  uteri,  764 ;  of  haemor- 
rhoids, 616 ;  of  joints,  868  ;  of  malignant  neo- 
plasms, 846;  of  Meckel's  ganglion,  473;  of 
moles,  301 ;  of  the  ankle-joint,  866,  374 ;  of  the 
breast,  519 ;  of  the  carpus,  381 ;  of  the  clavicle, 
533 :  of  the  colon,  540 ;  of  the  elbow,  377 ;  of 
the  eye,  416 ;  of  the  gall-bladder,  589 ;  of  the 
hip-joint,  368 ;  in  coxitis,  360  ;  of  the  inferior 
dental  nerve,  476 ;  of  the  interphalangeal  ar- 
ticulations, 381 ;  of  the  intestine,  539  ;  indica- 
tions for,  549 ;  of  the  kidney,  626  ;  of  the  knee- 
joint,  870 ;  in  suppuration,  864  ;  of  the  larynx, 
504 ;  of  the  lower  jaw,  475 ;  of  the  maxillary 
nerves,  473  ;  of  the  metacarpal  articulations, 
381 ;  of  the  oesophagus,  511  ;  of  the  parotid 
gland,  469;  of  the  prolapsed  rectum,  610;  of 


the  pylorus,  526,  529 ;  of  the  rectum,  606 ;  of 
the  ribs,  521,  523;  of  the  scapula,  533;  of  the 
shoulder-joint,  867,  376  ;  'of  the  spheno-maxil- 
lary  ganglion,  473 ;  of  the  spleen,  580 ;  of  the 
submaxillary  gland,  470;  of  the  tarsus,  819; 
of  the  testicle,  749  ;  of  the  thyroid  gland,  496 ; 
of  the  tongue,  484,  485 ;  of  the  tonsils,  490  ; 
of  the  upper  jaw,  473  ;  of  the  wrist-joint,  368, 
379;  of  vascular  tumors,  198;  of  wounds  in 
rabies,  82. 

Exophthalmic  goitre,  497. 

Exophoria,  433. 

Exostosis,  856:  of  the  skull,  885;  in  fractures, 
388. 

Expediency,  amputations  of,  107. 

Exploration  of  cranial  vault,  391 ;  of  kidney,' 
625  ;  of  urethra,  689,  et  seq. 

Exsection,  vide  excision. 

Exsector,  39. 

Exstrophy  of  the  bladder,  627 ;  operation  for, 
638. 

Extension,  after  exsection  of  hip,  360 ;  for  mor- 
bus coxoe,  358 ;  for  synovitis  of  hip,  352 ;  of 
knee,  362. 

External  carotid,  ligation  of,  244. 

External  iliac,  aneurism  of,  229 ;  ligation  of, 
266,  368. 

Extirpation,  vide  excision ;  of  angiomata,  197 ; 
of  lymphatic  glands,  164;  of  Meckel's  gan- 
glion, 472 ;  of  the  eye,  416 ;  of  the  fifth  nerve, 
473  ;  of  the  kidney,  636  ;  of  the  parotic  gland, 
469 ;  of  the  spleen,  586 ;  of  the  submaxillary 
gland,  470;  of  the  thyroid  gland,  496;  of  the 
upper  jaw,  473. 

Extraction  of  cataract,  430 ;  of  foreign  bodies 
through  the  urethra,  701 ;  of  the  teeth,  477. 

Eye,  396;  bandage  for,  20;  cysts,  sebaceous, 
of, '398;  enucleation  of,  416;  examination  of 
the,  435  ;  nasvi  near  the,  897  ;  new  formations, 
397 ;  plastic  operations  near  the,  397 ;  tumors 
near  the,  398 ;  syphilis,  736 ;  wounds,  897. 

Eyelids,  affections  of,  396,  et  seq. 

Fabrizzi.    Rhinoplasty,  450. 

Face,  bandage  for,  30 ;  contusions,  396 ;  guni 
shot-wounds,  396  ;  wounds,  395. 

Facial  artery,  ligation  of,  350. 

Facial  nerve,  injury  to,  in  extirpation  of  pa- 
rotid, 469  ;  in  ligation  of  external  carotid,  247. 

Fallopian  tubes,  inflammation  of,  770. 

False  aneurism,  302,  304. 

False  knot,  53. 

Fascia-knife,  35. 

Fasoiotomy  in  Dupuytren's  contraction,  881 ;  in 
pes  equino- varus,  818. 

Fecal  fistula,  549  ;■  diagnosis  and  treatment,  574, 

Fehleisen.     Erysipelas-coccus,  84. 

Felon,  884. 

Feinoral  artery,  aneurism  of,  230 ;  ligation  of. 
269. 


INDEX. 


869 


Peraoral  hernia,  554 ;  diagnosis  and  treatment, 
570. 

Femur,  307 ;  dislocations,  338 ;  fractures,  307, 
et  seq. ;  osteotomy,  802,  804. 

Ferguson.  Case  of  aneurism,  218,  327;  lithot- 
omy guide,  658. 

Fever  of  reaction,  53  ;  syphilitic,  721. 

Fibrin,  theory  of  formation  of,  168. 

Fibro-chondroraa,  856. 

Fibro-lipoma,  851. 

Fibroma,  853;  of  antrum  of  Highmore,  471 ;  of 
bladder,  640 ;  of  intestine,  530  ;  of  larynx,  506  ; 
of  lips,  455 ;  of  lower  jaw,  474 ;  of  mamma, 
516 ;  of  nipple,  513  ;  of  nose,  443 ;  of  parotid 
gland,  468 ;  of  tongue,  483  ;  of  tonsils,  490 ;  of 
urethra,  706. 

Fibromyoma  of  intestine,  536 ;  of  lower  jaw,  474 ; 
of  ovary,  776. 

Fibrous  union  in  fractures,  323. 

Fibula,  dislocations  of,  at  ankle,  848 ;  fractures 
of,  318. 

Fifth  nerve,  excision  of  branches  of,  473. 

Figure-of-eight  bandage,  12. 

Fingers,  amputation  of  the,  120 ;  bandages  for, 
13  :  contraction,  830  ;  deformities,  829 ;  disar- 
ticulation, 121 ;  jerk-,  832 ;  snap-,  832 ;  super- 
numerary, 829;  syphilis,  726;  webbed,  829. 

Fischer.  Case  of  aneurism,  230 ;  wounds  of  the 
heart,  524. 

Fissure  of  the  anus,  594,  599 ;  of  the  lips,  454 ; 
of  the  nares,  444 ;  of  the  nipple,  513 ;  of  the 
palate,  479. 

Fistule,  biliary,  584  ;  dissecting  out,  597 ;  fecal, 
549 ;  diagnosis  and  treatment,  574 ;  intestinal. 
549 ;  of  the  anus,  512,  595  ;  operation  for,  597 ; 
of  the  oesophagus,  512  ;  of  the  scrotum,  735  ; 
salivary,  466 ;  vesico-vaginal,  761. 

Fixation  of  knee,  for  suppuration,  364 ;  of  shoul- 
der, 367. 

Flap,  double  cresoentie,  117;  double  rectangu- 
lar, 118;  modified  circular  skin,  117;  mixed, 
118 ;  oblique  solid,  by  transfixion,  115 ;  by  out- 
ting  from  the  surface,  116;  oval,  117;  skin, 
circular,  116,  129 ;  solid,  circular,  110. 

Flaps,  formation  of,  in  amputation,  109, 116, 118. 

Plat-celled  epithelioma,  842. 

Flat  foot,  821. 

Fletcher.  Serpent -venom,  79  ;  treatment  of  ser- 
pent-bite, 79. 

Flexion  of  fingers,  830 ;  of  toes.  824. 

Flint.     Fatality  of  rabies,  82. 

Floating  kidney,  627. 

Fluhrer.  Case  of  penetrating  wound  of  skull, 
387 ;  swinging  cradle,  57. 

Flour,  for  burns,  94. 

Foot,  vide  ankle ;  also  amputations,  dislocations, 
etc. ;  bandage  for,  15. 

Forbes's  amputation  through  the  tarsus,  138. 

B'orceps,  anatomical-,  42 ;  artery-,  41 :  bone-,  38  ; 
for  extracting  teeth,  477 ;  for  foreign  bodies  in 


trachea,  503 ;  gouge.  39 ;  hfemostatic,  41 ;  lion- 
jawed,  39  ;  lithotomy-,  660;  mouse-toothed,  41, 
43 ;  needle-,  42,  77,  762  ;  phimosis-,  712  ;  sac-, 
777;  sequestrum-,  39;  Sims's  needle-,  762; 
urethral,  701. 

Fore-arm,  amputation  of,  127;  bandage  for,  14; 
fractures  of,  300.  ■ 

Foreign  bodies  in  the  anus,  595 ;  in  the  auditory 
canal,  438;  in  the  bladder,  645,  665;  in  the 
bronchial  tubes,  501;  in  the  cornea,  411 ;  in 
the  intestines,  530,  539 ;  in  the  larynx,  501 ;  in 
the  nose,  442 ;  in  the  oesophagus,  442,  507 ;  in 
the  pharynx,  507 ;  in  the  rectum,  531,  595 ;  in 
the  skull,  387 ;  in  the  stomach,  527 ;  in  the 
trachea,  501 ;  in  the  urethra,  700 ;  in  the  vit- 
reous humor,  423. 

Formation  of  capillaries  in  veins,  166 ;  in  wounds, 
69. 

Forster.     Pathology  of  tumors,  837. 

Foster.  Cataract,  419 ;  coagulation  of  blood, 
161. 

Four-tailed  bandage,  20. 

Fowl-bones  as  drains,  8. 

Pox-bite,  81. 

Practure-box,  320. 

Fractures,  280 ;  comminuted,  280 ;  complicated, 
280;  compound,  280,  284;  crepitus  in,  280; 
direct,  280 ;  fibrous  union  in,  323 ;  impacted, 
280;  indirect,  280;  of  the  acetabulum,  307; 
of  the  carpal  bones,  304 ;  of  the  clavicle,  292  ; 
of  the  coccyx,  306 ;  of  the  corpora  cavernosa, 
707;  of  the  femur,  307;  condyles  of,  313; 
great  trochanter,  312 ;  neck,  307 ;  shaft,  312 ; 
of  the  fibula.  318 ;  of  the  foot,  323 ;  of  the  fore- 
arm, 300 ;  of  the  head,  284 ;  of  the  humerus, 
295 ;  condyles  of,  297,  298 ;  neck,  anatomical, 
295 ;  surgical,  295 ;  shaft,  297 ;  tuberosities, 
295 ;  of  the  hyoid  bode,  292 ;  of  tlie  ilium,  307 ; 
of  the  inferior  maxilla,  289 ;  of  the  innominate 
bone,  306 ;  of  the  ischium,  307 ;  of  the  larynx, 
292 ;  of  the  leg,  318 ;  compound,  321 ;  of  the 
lower  jaw,  289;  of  the  malar  bone.  288,  289; 
of  the  metacarpal  bones,  287 ;  of  the  metatar- 
sal bones,  323;  of  the  nasal  bones,  287;  of  the 
patella,  314 ;  compound,  318 ;  of  the  penis, 
707 ;  of  the  phalanges,  305,  323  ;  of  th«  pubes, 
307 ;  of  the  radius,  300 ;  at  inferior  extremity 
of,  301;  diagnosis,  337;  at  superior  extrem- 
ity, 300  ;  of  the  ribs,  305  ;  of  the  sacrum,  306  ; 
of  the  scapula,  294;  at  acromion  process  of, 
294;  at  coracoid  process  of,  294;  at  glenoid 
process  of,  295 :  at  spine  of,  295 ;  of  the  skull, 
284;  at  its  base,  284,  395;  with  depression, 
284 ;  of  the  sternum.  305 ;  of  the  tarsus,  323 ; 
of  the  tibia,  318 ;  of  the  ulna,  300 ;  at  coronoid 
process,  300 ;  at  olecranon  process,  299 ;  of  the 
upper  jaw,  288;  of  the  vertebn-e,  305;  at  ar- 
ticular process,  306 ;  at  spinous  process,  306  ; 
of  the  zygomatic  process,  289 ;  partial,  280; 
prognosis,  283 ;    simple,  280 ;    subcutaneous. 


870 


A  TEXT-BOOK   ON  SURGERY. 


from  projectiles,  92 ;  symptoms  of,  381 ;  treat- 
ment of,  283 ;  ununited,  323. 
Franklin.     Phlebolites,  200. 
Freezing  mixtures  for  local  anaesthesia,  24, 
Freund.     Hysterectomy,  769. 
Frey.     Pathology  of  the  veins,  166. 
■  Fricke.    Heat  in  tetanus,  89. 
Friction-knot,  52. 

Frontal  bone,  gunshot-wounds  of,  90. 
Frontal  sinus,  445 ;  abscess  of,  384,  445. 
Frost-bite,  97. 
Fungi  in  inflammation,  60. 
Fungus  hematodes,  195. 
Puruncle,  97. 
Fusiform  aneurism,  202,  203. 

Galactocele,  517. 

Galbanum  in  lymphadenitis,  164. 

Gall-bladder,  584;  abscess  of,  584;  concretions, 
584 ;  distention  of,  diagnosis,  588. 

Gait.     Trephine,  40. 

Galvano-cautery  of  tongue,  485. 

Galvano-puncture  for  aneurism,  210;  for  angi- 
oma, 197;  for  vascular  tumors,  193. 

Ganglion,  830;  of  Meckel,  excision  of,  473. 

Gangrene,  100 ;  after  frost-bite,  97 ;  hospital, 
104 ;  in  chancre,  99 ;  of  scrotum,  734 ;  of  tissue 
in  inflammation,  56;  of  tissue  in  wounds,  69; 
senile,  103. 

Gant.  Excision  of  the  tongue,  487;  osteotomy 
of  femur,  802. 

Garreau.     Prostatic  syringe,  673. 

Gases  in  gangrene,  100. 

Gastrectomy,  526. 

Gastro-enterostomy,  528. 

Gastrostomy,  510,  535. 

Gastrotomy,  535,  note. 

Gauge  for  urethral  instruments,  698. 

Gauze,  disinfecting  of,  3 ;  preparation  of,  9. 

Gay.     Case  of  aneurism,  334 ;  phlebitis,  169. 

Genito-urinary  organs,  affections  of,  in  the  fe- 
male, 751 ;  in  the  male,  619. 

Genu  valgum,  804 ;  varum,  809. 

Germs  in  hospital  gangrene,  104;  vide  also 
micro-organisms. 

Gerster.  Case  of  aneurism  of  innominate  artery, 
317. 

Giant-celled  sarcoma,  844,  846. 

Gibney.    Morbus  cox®,  354 ;  Pott's  disease,  799. 

Gibson.     Excision  of  vascular  tumor,  193. 

Gila-monster,  venom  of,  80. 

Girdner.     Phimosis  forceps,  713 ;  skin-grafts,  95. 

Gland,  lachrymal,  etc.,  vide  lachrymal,  etc. 

Glanders,  83. 

Glaucoma,  417;  fulminans,  417,  437. 

Gleet,  686 ;  diagnosis,  673. 

Glenoid  process,  fracture  of,  295. 

Glioma,  846. 

Glossitis,  482. 

Glottis,  spasm  of,  in  ether  narcosis,  39. 


Glutaeal  artery,  aneurism  of,  230;  ligation  of,  367. 

Glutaeal  hernia,  555;  diagnosis  and  treatment, 
573. 

Goitre,  493;  cystic,  494;  exophthalmic,  497;  op- 
erations for,  495. 

Gonococcus,  677. 

Gonorrhoea,  676;  injections  in,  680;  in  the  fe- 
male, 685,  757;  syringe  for,  681;  treatment  of, 
679. 

Gonorrhoeal  bubo,  684;  ophthalmia,  408;  rheu- 
matism, 685. 

GoodwUlie.  Hollow  needle,  480 ;  mouth-gag, 
478 ;  periosteal  elevator,  37,  38. 

Gore.    Case  of  aneurism,  323. 

Gosselin.    Arterial  cirsoid  tumors,  190,  191,  194. 

Gouges,  38. 

Gouging  in  arthritis  of  ankle,  366 ;  of  wrist,  368. 

Goujon.     Experiments  on  tissue  formation,  56. 

Gouley.    Lithoclast,  661. 

Gout,  cause  of  arteritis,  173. 

Gouty  phlebitis,  168,  169. 

Gowan.    Exsector,  40. 

Gown,  operating,  49. 

Graefe.  Case  of  aneurism,  333  ;  excision  of  vascu- 
lar tumor,  193 ;  fixation  forceps,  420 ;  hare- 
lip, 460;  iridectomy,  414;  linear  knife,  430; 
speculum,  430;  strabismus-hook,  435. 

Grafting  of  skin  for  burns,  94;  Thiersch's  meth- 
od of,  95. 

Granular,  cells  in  wounds,  70 ;  corpuscles,  com- 
pound, 63 ;  metamorphosis  in  wounds,  70. 

Graves's  disease,  497. 

Green.  Calcareous  deposits  in  veins,  199 ;  coagu- 
lation of  blood,  168;  endarteritis,  176,  187. 

Greenfield.     Syphilitic  arteritis,  183,  187. 

Gritti's  amputation  at  the  knee,  153. 

Grooved  director,  44. 

Gross.  Cavernous  tumors,  196:  ligation  of  in- 
ternal jugular  vein,  353 ;  nsevoid  elephantiasis, 
196;  phlebitis,  168;  phlebolites,  300;  sarcoma 
of  bone,  845. 

Gruening.    Depilating  forceps,  407. 

Gueniot.     Excision  of  vascular  tumor,  193. 

Gum-lancet,  37. 

Gummata,  722 ;  differential  diagnosis  from  fu- 
runcle, 98 ;  of  tongue,  484. 

Gunderloeh  and  Miiller.  Ligation  of  carotid  for 
vascular  tumor,  193. 

Gunshot  missiles,  91 ;  wounds,  68 ;  haemorrhage 
from,  71;  of  the  abdomen,  587;  of  the  ali- 
mentary canal,  588 ;  of  the  bladder,  639 ;  of 
the  brain  and  membranes,  386 ;  of  the  chest, 
533;  of  the  face,  396;  of  the  hand,  case  of, 
832 ;  of  the  heart,  534 ;  of  the  neck,  493 ;  of 
the  skull,  386. 

Gunther's  amputation,  145. 

Gypsum  bandages,  10;  for  fractures,  396,  311. 

Hiematin,  causing  redness  in  inflammation,  55. 
Haematocele,  735. 


INDEX. 


871 


HsBmatoma  of  the  cord.  741 ;  of  the  tunica  vagi- 
nalis, 735  ;  of  the  vulva,  751. 

HsEmaturia,  619,  64-3. 

Hemorrhage  after  extraction  of  teeth,  477  ;  from 
moles,  201 ;  in  gunshot-wounds,  31,  92 ;  in  hos- 
pital gangrene,  105;  in  operations  on  the 
tongue,  485;  method  of  controlling,  486;  of 
the  kidneys,  619. 

Hferaorrhoids,  198,  611;  external,  64;  internal, 
611,  613  ;  ulcers  after,  600,  601. 

Hiemostasis,  methods  of,  51 ;  in  wounds,  71 ;  in 
vessels  wounded,  71,  73. 

Hiemostatic  forceps,  41. 

Hairs  on  the  lip  455. 

Hale.    Urethral  forceps,  701. 

Hall.    Case  of  aneurism,  223. 

Hallux  valgus.  823. 

Hamilton.  Dislocation  at  elbow,  337;  fracture 
of  humerus,  398 ;  of  lower  jaw,  apparatus  for, 
291 ;  of  malar  bone,  288  ;  of  olecranon,  299  ; 
of  patella,  315 ;  of  radius,  303 ;  of  thigh,  long- 
splint  in,  309 ;  head-stall,  326  ;  long  splint,  for 
osteotomy  of  femur,  802;  for  morbus  eosse, 
359 ;  phlebitis,  168 ;  sequestrum  forceps,  39  ; 
treatment  of  dislocation  of  hip-joint,  343,  345, 
346. 

Hammer,  38. 

Hammer-toe,  834. 

Hancock.  Disarticulation  at  calcaneo-astraga- 
loid  joint,  140;  operation  for  peritonitis,  578. 

Hand,  amputation  of,  120 ;  bandages  for  the,  13 ; 
contractions  of,  831 ;  deformities,  829 ;  disin- 
fection of,  3 ;  phlegmons  of.  834. 

Handkerchief-bandages,  20. 

Harelip,  456;  double,  457;  operation  for,  458; 
of  Colles,  460 ;  of  Graefe,  460 ;  of  Koenig,  460 ; 
of  Langenbeck,  459 ;  of  Malgaigne,  459 ;  of 
Nelaton,  459. 

Harris.    Tooth-forceps,  477. 

Hart.     Excision  of  vascular  tumor,  193. 

Haussmann.     Epithelioma  of  intestine,  536. 

Hayden.     Case  of  aneurism,  224. 

Head,  bandages  for,  18,  19, 20 ;  gunshot-wounds, 
387;  injuries  and  affections,  382;  net,  21; 
wounds,  386. 

Headache,  syphilitic,  721. 

Healing  of  wounds,  78. 

Heart,  524 ;  gunshot- wounds,  534  ;  syphilis,  724 ; 
wounds,  534. 

Heart-failure  in  ether  and  chloroform  narcosis, 
32. 

Heat,  as  a  haemostatic  in  wounds,  73  ;  bodily,  in 
tetanus,  89 ;  in  inflammation,  54 ;  treatment 
of  gangrene  by,  101 ;  of  inflammation  by,  60. 

Heath.    Case  of  aneurism,  215,  316,  217. 

Heine.     Excision  of  vascular  tumor,  192. 

Heitzmann.  Structure  of  arteries,  173 ;  of  veins, 
165. 

Heloderma  suspectum,  80. 

Hemeralopia,  424. 


Hemianopsia,  424. 

Hemiglossitis,  482. 

Hemiplegia,  operation  for,  391. 

Henle.     Prostatic  muscle,  639. 

Henry.     Scrotal  clamp,  734. 

Hepatic  abscess,  582. 

Hernia,  550 ;  cerebral,  385  ;  diagnosis,  556,  736 ; 
diaphragmatic,  555 ;  treatment,  573;  femoral, 
553 ;  diagnosis  and  treatment,  570  ;  operation 
for,  571 ;  gangrenous,  539  ;  gluteal,  555  ;  in- 
guinal, 550  ;  irreducible,  572  ;  lumbar,  555 ; 
needles,  563 ;  obturator,  555  ;  of  the  bladder, 
629;  of  the  brain,  385;  of  the  labium,  758;  of 
the  lungs,  534  ;  of  the  ovary,  758 ;  of  the 
spleen,  586 ;  omental,  diagnosis,  738 ;  opera- 
tion for,  McBurney's,  559 ;  Macewen's,  562 ; 
radical  cure  for,  559 ;  statistics  of,  550 ;  stran- 
gulated, 566 ;  treatment  of,  558  ;  truss  for,  558 ; 
umbilical,  554 ;  diagnosis  and  treatment,  572  ; 
vaginal,  555 ;  ventral,  554 ;  treatment  of,  573 ; 
vesical,  629. 

Herpes,  corneal,  412;  of  anus,  594;  of  penis, 
713. 

Heterophoria,  433. 

Hey.  Modification  of  Lisfranc's  amputation 
of  the  foot,  137 ;  saw  for  elevation  of  cranium, 
893. 

Heubner.     Syphilitic  arteritis,  188. 

Hewitt.     Pruritus  vulvse,  758. 

Hewson.     Case  of  aneurism.  319. 

Highmore.  Antrum  of,  affections  of,  471,  vide 
antrum. 

Hilton.    Case  of  aneurism,  337. 

Hip-joint,  anchylosis  of,  801  ;  amputation  at, 
154,  158 ;  bursitis  of,  857 ;  deformities,  801 ; , 
disease,  353;  treatment  of,  358;  dislocations, 
338  ;  exsection,  368 ;  neuralgia,  357 ;  osteoto- 
my near  the,  803 ;  ostitis,  857  ;  rheumatism  of 
muscles  of,  357 ;  synovitis,  357 ;  tuberculosis, 
354. 

Hobart.  Case  of  aneurism,  215 ;  case  of  ligation 
of  subclavian  and  carotid,  357. 

Hodges.     Case  of  aneurism,  219. 

Hodgkins.     Disease,  163. 

Hodgson.     Phlebolites,  200. 

Holder;  Lid,  402;  needle,  42,  77;  knife,  765; 
vide  apparatus. 

Holding.     Method  of,  scalpel,  51. 

Holmes.  Arterial  cirsoid  tumor,  191 ;  case  of 
aneurism,  316,  219,  336;  elastic  ballfor  com- 
pression in  aneurism,  337 ;  phlebolites,  300. 

Holmgren.    Color  tests,  434. 

Holt.     Self-retaining  catheter,  638. 

Homatropine,  428. 

Hood-bandage,  20. 

Hordeolum,  399. 

Horse-hair  for  drains,  78  ;  in  aneurism,  310. 

Hornet-sting,  81. 

Horns  of  the  scalp,  383. 

Horsley.     Brain-surgery,  891. 


872 


A  TEXT-BOOK  ON   SURGERY. 


Hosjjital  gangrene,  104. 

Hot  water  for  controlling  hfemorrhage  in   the 

brain,  393. 
Howship's  caverns    in  ,  inflammation   of    bone, 

275. 
Humerus,  dislocations  of,  337 ;  fracture,  295, 
Humphrey.     Amputation  of  the  penis,  709. 
Hunter.     Aneurism,  ligation  of  arteries  in,  307, 

r     209. 

Hunter,  J.  B.     Vaginal  hysterectomy,  765. 

Hutchison.  Case  of  aneurism,  319  ;  shoe  in 
morbus  coxa?,  359. 

Hutchinson.     Najvi,  197 ;  phlebitis,  168,  169. 

Hutton.     Case  of  aneurism,  318. 

Hyalitis,  433. 

;Hydatids  of  the  bladder,  640 ;  of  the  gall-blad- 
der, 584 ;  of  the  kidney,  633,  633  :  of  the  liver, 

;    583 ;  of  the  mammary  gland,  517 ;  of  the  thy- 

; ,_  roid  gland,  494,  497. 

Hydrocele,  735;  diagnosis,  557;  bilocular,  737; 
congenital,  736 ;  encysted,  738 ;  of  the  sper- 
matic cord,  735 ;  radical  cure  of,  730 ;  symp- 
toms, 737 ;  treatment,  738. 

Hydrocephalus,  386  ;  tapping  for,  386. 

Hydrogen  gas  in  intestinal  wounds,  588; 

Hydroma,  165. 

Hydronephrosis,  631 ;  diagnosis,  579. 

Hydrophobia,  81. 

Hydrops  of  antrum  of  Highmore,  471. 

Hydropyonephrosis,  631. 

,'Hydrorhaehis,  799.       ,         i, 

Hyoid  bone,  fracture  of,  392. 

Hypersemia  in  inflammation,  54,  55. 

Hyperdistention  of  abscess,  64. 

Hypermetropia,  436,  438,  429. 

Hyperostosis  of  antrum,  471. 

Hyperphoria,  433.  • 

Hyperplasia  of  parotid  gland,  468;   of  thyroid 

,  _  gland,  493. 

Hypertrophy  of  the  auricle,  438 :    of  the  lips, 

J, I  445  ;  of  the  mammary  gland,  515  ;  Of  the  mu- 
cous membrane,  443  ;  of  the  nose,  446  ;  of  the 
parotid  gland,  468  ;  of  the  prostate  gland,  666 ; 
of  the  skin,  201  :  of  the  thyroid  gland,  493  ;  of 
the  tongue,  483 ;  of  the  tonsils,  490 ;  of  the 

;  r-tUrt)inated  tufts,  444.  ..  . 

Hypodermic  injections  of  carbolic  acid  in  erysip- 
elas, 87;  of  cocaine,  22,  23  ;  of  ergot  as  a  hasmo- 

i,-  static,  77;  of  whisky,  37,  32 ;  in  syncope,  77. 

Hypodermic  syringe,  in  diagnosis  of  abscess,  64 ; 
of  synovitis  of  the  knee,  362. 

Hypopyon,  413. 

Hypophosphites  in  furuncle,  97 ;  in  morbus  coxa?, 
360 ;  in  rhaphitis,  279. 

Hypospadias,  705. 

Hysteria,  89. 

Hysterectomy,  abdominal,  766;  during  pregnan- 
cy, 768 ;  for  fibro-myomata,  769,  770 ;  vaginal, 
765. 

Hysterotomy,  766. 


Ice-bag,  58. 

Idiopathic  arteritis,  177;  phlebitis,  168,  169. 

Ileocolitis  after  ether  narcosis,  33. 

Ileo-colostomy,  550. 

Iliac  artery,  common,  aneurism  of,  229;  com- 
pression of,  73,  154  ;  ligation  of,  264  ;  external, 
aneurism  of,  229;  ligation  of,  266-268;  for 
femoral  aneurism,  230 ;  internal,  aneurism  of, 
339  ;  ligation,  366. 

Ilium,  fracture  of,  307. 

Immediate  amputations,  107 ;  exsection  of  stran- 
gulated intestine,  569. 

Impactions  of  cerumen  in  the  ^ar,  439 ;  of  fecal 
matter  in  the  intestine,  530. 

Imperforate  anus,  574. 

Incised  wounds,  68. 

Incisions  in  anthrax,  84;  in  carbuncle,  98;  in 
dislocations,  322 ;  in  erysipelas,  87 ;  in  furun- 
cles, 97 ;  in  gangrene,  102,  103 ;  in  hospital 
gangrene,  105 ;  in  inflammation,  57 ;  in  lym- 
phadenitis, 164;  in  lymphangitis,  163;  in  mor- 
bus coxas,  360 ;  in  periostitis,  277 ;  in  phlebitis, 
171 ;  in  suppurations  of  the  knee-joint,  363  ; 
of  the  shoulder-joint,  367;  in  swelling  after 
serpent-bites,  80;  in  tetanus,  89. 

Incision  of  abdomen  for  intestinal  occlusion, 
538 ;  of  cold  abscess,  66 ;  of  pi'epuce,  713. 

Incontinence  of  urine,  638. 

Incubation  of  erysipelas,  84 ;  of  rabies,  82. 

Indications  for  amputation,  108 ;  for  change  of 
dressings,  53,  115;  for  the  substitution  of 
chloroform  for  ether,  25. 

Index-finger,  amputation  of,  133. 

Indolent  ulcer,  99. 

Infantile  hernia,  553. 

Infected  surfaces,  iodoform  on,  5. 

Inferior  maxilla,  dislocation  of,  325,  vide  jaw. 

Inferior  thyroid  artery,  ligation  af,  259. 

Infiltration  of  urine,  630. 

Inflammation,  54;  abscesses  in,  63;  acute,  54; 
bleeding  in,  57  ;  calomel  in,  64 ;  causes  of,  54 ; 
cicatrization  in,  54 ;  cold  applications  in,  58 ; 
compression  in,  58 ;  constriction  of  arteries  in, 
58 ;  counter-irritants  in,  60 ;  formation  of 
capillaries  in,  69  ;  heat  in,  54 ;  in  treatment  of, 
58 ;  in  bone,  375 :  local  symptoms  of,  34 ;  of 
penis,  706 ;  pain  in,  54 ;  phenomena  of,  54 ; 
poultices  in  treatment  of,  58;  resolution  in, 
56 ;  suppuration  in,  67 ;  swelling  in,  54  ;  symp- 
toms of,  54 ;  treatment  of,  58 ;  venesection  in, 
57 ;  vesicants  in,  59  ;  warm  applications  in,  58 ; 
without  sepsis,  60. 

Ingrowing  nail,  825. 

Inguinal  bubo,  684,  715. 

Inguinal  hernia,  550;  congenital,  553;  diagnosis 
of,  556 ;  symptoms  of,  555  ;  in  the  female,  570. 

Inhalers,  ether-,  28. 

Inherited  syphilis,  733. 

Injections,  hypodermic,  vide  hypodermic ;  of 
carbolic  acid  in  erysipelas,  81 ;  of  cocaine,  33. 


INDEX. 


873 


Injections,  in  aneurism,  210;  in  arterial  varix, 
190  ;  in  gonorrhcea,  680;  in  hydrocele,  738;  in 
vascular  tumors,  193. 

In-knee,  804. 

Innominate  artery,  aneurism  of,  312.216;  liga- 
tion of,  235 ;  for  subclavian  aneurism,  228. 

Innominate  bone,  fracture  of,  30. 

Inoculation,  for  rabies,  82  ;  in  tetanus,  88. 

Instruments,  surgical,  35 ;  disinfection  of,  3 ; 
trays  for,  48. 

Intercostal  arteries,  ligation  of,  262. 

Intercostal  artery,  superior,  ligation  of,  256. 

Interdental  splints,  290. 

Intermediate  suture,  343. 

Internal  carotid  artery,  ligation  of,  243 ;  jugu- 
lar vein,  ligation  of,  237,  253;  iliac  artery, 
aneurism  of,  229 ;  ligation  of.  266 ;  mammary 
artery,  ligation  of,  255,  259  ;  maxillary  artery, 
ligation  of,  353 ;  pudic  artery,  ligation  of,  268. 

Interphalangeal  amputations,  120 ;  exsections, 
381 ;  joints,  synovitis  of,  368. 

Interrupted  suture,  53,  57. 

Intestine,  concretions  in,  530;  constriction  of, 
835 ;  exsection  of,  539  ;  fistula  of,  549  ;  foreign 
bodies  in,  331 ;  gunshot-wounds  of,  588 ;  in- 
ternal strangulation,  535  ;  intussusception,  532 ; 
obstruction,  530;  occlusion  of,  abdominal  sec- 
tion for,  538  ;  puncture  of,  in  obstruction,  538 ; 
suture  of,  528.  542,  543,  589 ;  wounds  of,  587. 

Indraa,  in  endarteritis,  176;  of  arteries,  172;  of 
veins,  162;  rupture  of,  a  cause  of  arteritis, 
174. 

Intraperitoneal  abscess,  579. 

Intratrochanterie  section  of  femur,  803. 

Intravenous  injections,  78,  620. 

Intussusception,  532,  539. 

Invagination  of  intestines,  532. 

Involucrum,  275. 

Iodides,  in  aneurism,  306 ;  in  furuncle,  97 ;  in 
goitre  (cystic),  495 ;  in  Pott's  disease,  799 ;  in 
syphilis,  730. 

Iodine  in  spina  bifida.  800. 

Iodoform  as  an  antiseptic,  3  ;  for  amputations, 
110 ;  gauze,  9 ;  in  war,  93 ;  in  hospital  gan- 
grene, 105 ;  solution  of,  in  ether,  5 ;  supposi- 
tories, 602,  607 ;  vaseline  for  burns,  94 ;  for 
ulcers,  100. 

Iridectomy,  412,  415,  417;  with  extraction  of 
cataract.  421. 

Iris-forceps,  417. 

Iris-scissors,  417. 

Iris,  syphilis  of  the,  415,  722,  726. 

Iritis,  415  ;  rheumatic,  415 ;  syphilitic,  415,  723, 
726. 

Iron,  chloride  of,  in  aneurism,  206,  211  ;  in  fu- 
runcles, 97;  perohloride  of,  in  phlebitis,  171 ;  in 
vascular  tumors,  193,  197. 

Iron-dyed  silk  for  sutures,  3. 

Irrigation,  continuous,  5  ;  in  amputations,  120 ; 
during  operation,  52 ;   In  inflammation,  58 ; 


of  knee-joint,  363;  of  wounds,  3,  51,  74;  of 
gunshot-wounds,  92. 

Irrigator,  6,  7. 

Irritable  ulcers,  100. 

Irritation,  a  cause  of  inflammation,  55 ;  of  ma- 
lignant tumors,  840. 

Ischium,  fi-acture  of,  307. 

Isolation  of  patients  for  hospital  gangrene,  106. 

Jaeger's  keratome,  417;  lid-holder,  402. 

James.     Case  of  aneurism,  329. 

Janeway.     Case  of  albuminuria,  642. 

Jarvis's  snare,  443. 

Jaw,  lower,  470;  affections  of,  474;  anchylosis, 
476 ;  bandage  for,  118 ;  dislocation,  325  ;  ex- 
cision, 475  ;  fracture,  289 ;  necrosis,  471 ;  phos- 
phorus disease,  471 ;  upper,  471 ;  abscess,  470 ; 
excision,  473 ;  fractures,  389 ;  syphilis,  471. 

Jequirity  in  pannus,  412. 

Jerk-finger,  832. 

Joints,  diseases  of  the,  351 ;  surgery  of  the,  325 ; 
syphilis,  734. 

Jones,  Sydney.    Excision  of  vascular  tumor,  193. 

Jones,  Wharton.     Ectropion,  402. 

Jugular  vein,  ligation  of,  237,  353;  wounds  of, 
in  ligation  of  the  carotid,  238. 

Juniper-oil  for  bone-drains,  8 ;  for  catgut,  3, 

Jury  mast,  791,  795. 

Jute,  9. 

Keen.     Brain-surgery,  393. 

Keith.     Hysterectomy,  770. 

Kelotomy,  566. 

Kelsey.     Hsemorrhoidal  syringe,  563. 

Keratitis,  411 ;  dilfuse,  411 ;  herpetic,  412  ;  phlye- 
tjenular,  413 ;  secondary,  413 ;  traumatic,  412 ; 
ulcerative,  412. 

Key.     Case  of  aneurism.  219. 

Keyes.  Operation  for  varicocele,  741 ;  varicocele 
needle,  741 ;  wire  stylet,  636. 

Key-hole  saw,  37. 

Kidney,  619 ;  abscess  of  the,  620 ;  calculi,  620, 
632,  636,  646 ;  carcinoma,  634 ;  contusions,  619 ; 
cysts,  633;  displacement,  637;  dropsy,  631; 
encephaloid,  624 ;  exploration  of,  625 ;  extir- 
pation, 626;  floating,  637;  hsemori'hage  from, 
619 ;  hydatids,  633 ;  hydronephrosis,  621  ;  tu- 
mors, 623 ;  syphilis,  725 ;  wounds,  619. 

King.  Case  of  aneurism,  217;  snake-bite,  79; 
scrotal  clamp,  743. 

Kingdon.     Hernia  statistics,  550. 

Kiotome,  671. 

Knapp.    Entropion  clamp,  404. 

Knee,  aifeetions  of,  362;  amputation  at,  150;. 
anchylosis,  810 ;  bandage  for  the,  16 ;  disloca- 
tions, 346 ;  exsection,  370 :  knock-,  804 ;  osteo- 
arthritis of,  363 ;  synovitis,  362. 

Knife-holder,  765. 

Knives,  amputating,  35. 

Knock-knee,  804 


874 


A  TEXT-BOOK   ON   SURGERY. 


Knot,  52,  75 ;  double,  52 ;  friction,  52 ;  in  intes- 
tinal sutures,  543;  in  sutures,  75;  surgeon's, 
52 ;  reef,  52. 

Knotted  bandage,  19. 

Koch.     Corrosive  sublimate,  3. 

Kooher.  Dislocation  of  humerus,  treatment  of, 
328  ;  excision  of  tongue,  487 ;  myscsdema 
after  goitrous  tumors,  495 ;  thyroidectomy, 
497 ;  tumors  of  epididymis,  744. 

Koenig.     Harelip,  460 ;  rhinoplasty,  448. 

Koller.     Cocaine,  22. 

Krackowitzer.  Cirsoid  aneurism,  194;  entero- 
vesical  fistula,  575. 

Kiihl.  Case  of  ligation  of  subclavian  and  ca- 
rotid, 257;  ligation  of  carotid  for  vascular 
tumor,  193. 

Kunkler.    Snake-bite,  79. 

Labial  hernia,  758. 

Labat.     Rhinoplasty,  448. 

Lacerated  wounds,  68,  75;  of  face,  396. 

Laceration  of  cervix  uteri,  763. 

Lacerda.    Treatment  of  snake-bite,  801. 

Lachrymal  gland,  affections  of,  405 ;  extirpation, 
405." 

Lachrymal  sac,  abscess  of,  405. 

Ladinski,  operating  table,  45. 

Lambert.     Case  of  aneurism,  321. 

Lagophthalmus,  400. 

Lane.    Case  of  aneurism,  219. 

Lange.  Case  of  aneurism,  ligation  of  common 
iliac,  230. 

Langenbeek.  Harelip,  445 ;  incision  in  exsection 
of  wrist,  379 ;  operation  for  tumor  of  antrum 
of  Highmore,  472  ;  rhinoplasty,  448. 

Laparotomy  for  occlusion  of  intestine,  538 ;  for 
ovariotomy,  776. 

Larrey's  method  of  amputating  at  the  shoulder- 
joint,  133. 

Laryngeal  symptoms  in  aneurism,  211 ;  tubes, 
499. 

Laryngectomy,  504  ;  partial,  505. 

Laryngotomy,  498 ;  for  foreign  body,  502. 

Laryngo-tracheotomy,  499. 

Larynx,  498 ;  foreign  bodies  in  the,  501 ;  fract- 
ure, 291 ;  syphilis,  724 ;  tubes  for,  499. 

Lateral  curvature  of  the  spine,  779;  cervical, 
779 ;  dorsal,  782. 

Lateral  deviation  of  the  septum  of  the  nose,  445'; 
lithotomy,  658. 

Lawrence.    Strabismometer,  425. 

Laxatives  in  erysipelas,  87. 

Lead  and  opium  wash  in  lymphangitis,  163;  in 
synovitis,  352 ;  subacetate  of,  in  ulcers  of  the 
penis,  716. 

Lediard.    Case  of  aneurism,  215. 

Lee.    Amputation  of  the  leg,  147. 

Leeches,  57 ;  in  epididymitis,  745 ;  in  inflamma- 
tion, 57. 

Le  Port.    Amputation,  144. 


Leg,  bandages  for,  16 ;  amputation  of  the,  146 ; 
fractures,  318. 

Lembert.  Suture  of  the  intestine,  528, 542,  589 ; 
for  the  uterus,  768. 

Leopold.     Hysterectomy,  766. 

Lens,  affections  of  the,  418. 

Leucocytes,  behavior  of,  in  inflammation,  55 ; 
formation  of  capillaries  by,  in  wounds,  70. 

Leucocythtemia,  586. 

Leucoma,  414. 

Levis.  Extrophy  of  the  bladder,  operation  for, 
628 ;  hydrocele,  operation  for,  739. 

Ligation,  arterial,  73,  234;  in  amputations,  113; 
knots  in,  52;  of  haemorrhoids,  614;  of  the 
abdominal  aorta,  264 ;  for  iliac  aneurism,  229 ; 
statistics  of,  266 ;  of  the  anterior  tibial  arter)-, 
273 ;  of  the  ascending  pharyngeal,  250 ;  of  the 
axillary,  259 ;  of  the  brachial,  261 ;  of  the  com- 
mon carotid,  237 ;  for  occipital  lesions,  252 ; 
statistics  of,  247 ;  of  the  common  femoral,  271 ; 
of  the  common  iliac,  264;  statistics  of,  266;  of 
the  dorsal,  of  the  foot,  274;  of  the  external 
carotid,  244;  for  extirpation  of  the  parotid 
gland,  469 ;  for  wounds  of  the  face,  396 ;  sta- 
tistics of,  247 ;  of  the  external  iliac,  266,  268 ; 
of  the  facial,  250 ;  of  the  femoral,  269 ;  of  the 
gluteal,  267;  of  the  inferior  thyroid,  259;  of 
the  innominate,  235 ;  of  the  intercostal  arteries, 
262;  of  the  internal  carotid,  242;  statistics  of, 
244;  of  the  internal  iliac,  266;  statistics  of, 
267;  of  the  internal  maxillary,  253  ;  of  the  in- 
ternal pudic,  267 ;  of  the  lingual,  248,  483 ;  of 
the  occipital,  250 ;  of  the  pharyngeal,  ascend- 
ing, 250 ;  of  the  popliteal,  271 ;  of  the  posterior 
auricular,  252 ;  of  the  posterior  tibial,  272 ;  of 
the  profunda  femoris,  271 ;  of  the  radial,  262 ; 
of  the  sciatic,  267 ;  of  the  subclavian,  134,  253 
et  seq.,  256,  258  ;  statistics,  259 ;  of  the  superior 
thyroid,  248;  of  the  temporal,  253;  of  the 
ulnar,  262 ;  of  the  vertebral,  259 ;  of  varicose 
veins,  200. 

Ligature,  1 ;  as  haemostatic,  1 ;  animal,  1 ;  appli- 
cation of,  52;  arteritis  after,  188;  broad,  1 ; 
during  operation,  48 ;  elastic,  41 ;  for  aneu- 
rism, 206,  209 ;  for  arterial  varix,  190,  232. 

Lignerol.  Disarticulation  at  calcaneo-astraga- 
loid  Joint,  139. 

Lime-water  and  oil  for  burns,  93. 

Line  of  demarkation,  in  gangrene,  101. 

Lingual  artery,  ligation  of,  248. 

Linhart.     Rhinoplasty,  448. 

Linseed-oil  and  lime-water  for  burns,  98. 

Lion-jawed  forceps,  39. 

Lip,  carbuncle  of,  455 ;  cysts,  455  ;  epithelioma, 
453 ;  fatty  tumors,  455  ;  fibroid  tumors,  455  ; 
fissure,  455  ;  hair  on,  455 ;  hare-,  456 ;  hyper- 
trophy of,  445  ;  moles,  455  ;  n^vus,  455  ; 
phlegmon,  455 ;  plastic  operations  on,  462 ; 
syphilitic  ulcers,  453;  ulcers,  453;  wounds, 
452. 


INDEX. 


875 


Lipoma,  851 ;  of  intestine,  536 ;  of  lip,  455 ;  of 
neck,  493 ;  of  scalp,  383  ;  of  tongue,  483. 

Liquefaction  of  tissues  by  micro-organisms,  61. 

Liquor  puris,  61. 

Liquor  sodae  chlorinatae  for  gauze,  9  ;  for 
sponges,  5. 

Lisfrane.     Amputation,  137. 

Liston.  Case  of  aneurism,  224  ;  ligation  of  sub- 
clavian and  carotid,  357;  treatment  of  dislo- 
cations of  the  elbow,  336. 

Lithiasis  oonjunetivie,  411. 

Lithoelast,  661. 

Lithotomy,  654 ;  bilateral,  663 ;  forceps,  660  ; 
guide,  661,  663 ;  instruments,  661 ;  knives,  35  ; 
labial,  658 ;  lateral,  658 ;  median,  663 ;  peri- 
neal, 658 ;  scoop,  661 ;  suprapubic,  654,  657, 
664;  vesico- vaginal,  664. 

Lithotrity,  650. 

Little.  Case  of  aneurism,  217,  227 ;  lithotomy- 
knife,  36 ;  lithotomy-staff,  663. 

Little  finger,  amputation  of,  123 ;  disarticula- 
tion of,  at  carpo-metacarpal  joint,  125. 

Littre.     Colostomy,  576. 

Liver,  582 ;  abscess  of,  582 ;  carcinoma,  583 ; 
diagnosis,  584 ;  hydatids,  583 ;  syphilis,  725. 

Lizard,  venom  of,  80. 

Lizars.  Case  of  aneurism,  223 ;  case  of  ligation 
of  innominate,  237. 

Lobular  epithelioma,  841. 

Local  anaesthesia,  22,  24 ;  vide  cocaine. 

Localization  of  motor  paralyses,  in  brain-centers, 
389. 

Lock-jaw,  88. 

Loeffler.     Glanders,  83. 

Lordosis,  787. 

Lower  extremity,  deformities  of  the,  801 ;  jaw, 
vide  jaw. 

Lucas  -  Championniere.  Cerebral  localization, 
389. 

Lumbar  hernia,  555. 

Lupoid  ulcer  of  rectum,  500. 

Lupus,  of  cheek,  454;  of  conjunctiva,  410;  of 
lip,  454 ;  of  nose,  454  ;  of  vulva,  757. 

Lustgarten.     Syphilis  bacilli,  717. 

Luxations,  vide  dislocations. 

Lymph-fistula,  165. 

Lymphadenitis,  164;  syphilitica,  724. 

Lymphadenoma,  843,  855 ;  of  kidney,  624. 

Lymphangiectasis,  493. 

Lymphangioma,  165,  854. 

Lymphangitis,  84,  86,  162 ;  acute,  162 ;  chronic, 
163 ;  diagnosis,  163 ;  in  erysipelas,  86 ;  of  the 
penis,  715;  subacute,  163;  sj'philitic,  719,  722; 
treatment,  163. 

Lymphatic  glands,  inflammation  of,  164 ;  vessels, 
diseases  of,  162 ;  inflammation  of,  84,  162 ; 
wounds  of,  165. 

Lymphoma,  165 ;  of  the  neck,  493,  494 ;  of  the 
tonsil,  490. 

Lympho-sarcoma  of  neck,  495. 


Macewen.  Fowl-bone-drains,  8 ;  opei-ation  for 
genu  valgum,  807,  808 ;  operation  for  hernia, 
562. 

Mackenzie.     Tonsillotome,  490. 

Mackintosh,  9. 

Macnamara.     Drilling  in  morbus  coxa?,  361. 

Maculas,  414. 

Macular  syphilide,  700. 

McBurney.  Operation  for  hernia,  559 ;  urethral 
fistula,  702. 

McCarthy.    Case  of  aneurism,  217. 

McCormac.     Operation  for  genu  valgum,  809. 

McCosh.    Exseotion  of  intestine,  569. 

McGuire.     Case  of  aneurism,  229. 

Malarial  fever,  a  cause  of  haematuria,  643. 

Malformations  of  the  anus  and  rectum,  591 ;  of 
the  urethra,  705. 

Malgaigne.  Case  of  aneurism,  217;  disarticula- 
tion at  calcaneo-astragaloid  joint,  139 ;  hooks 
for  patellar  fracture,  317 ;  operation  for  hare- 
lip, 459. 

Malignant  pustule,  83 ;  tumors,  839. 

Mallet,  38. 

Malleolus,  dislocations  of,  348 ;  fractures,  318. 

Malpositions  of  the  testicle,  750. 

Mammary  artery,  internal,  255  ;  ligation  of,  259- 

Mammary  gland,  513;  abscess  of,  514;  adenoid 
tumors,  515 ;  affections  of,  513 ;  amputation 
of,  519;  angioma,  513;  bandage  for,  17;  col- 
loid, 518;  cystic  tumors,  517;  defect,  513;  en- 
cephaloid,  518 ;  epithelioma,  519 ;  fibroma, 
516 ;  hypertrophy,  515 ;  inflammation,  513, 
514:  malignant  tumors,  515;  sarcoma,  517; 
scirrhus,  518 ;  syphilis,  515;  tuberculosis,  517; 
tumors,  515. 

Manual  compression  in  the  treatment  of  aneu- 
rism, 210,  227. 

Marion-Sims,  H.  Drainage-tube  for  pelvis  after 
laparotomy,  778 ;  ether-inhaler,  29 ;  inconti- 
nence of  urine,  639 ;  urethral  speculum,  706. 

Marsden's  paste,  444. 

Martin.     Bandage,  99 ;  for  varix,  200. 

Mask,  for  ether  inhalation,  28. 

Mason,  Brskine.     Amputation  at  hip,  155. 

Mason,  L.  D.  Steel  drills  in  fracture  of  nasal 
bones,  287. 

Massage  in  the  treatment  of  aneurism,  210,  227. 

Mastitis,  514. 

Mastoid  oells,  affections  of  the,  440,  441 ;  drain- 
age of  the,  441. 

Mattress  suture,  75. 

Maunders.     Case  of  aneurism,  215. 

Maxilla,  vide  jaw ;  inferior,  dislocation  of,  325 ; 
fracture  of,  289. 

Maxillary  artery,  internal,  ligation  of,  253. 

Meatotomy,  691. 

Mechanical  compression  in  the  treatment  of 
aneurism,  208. 

Meckel,  diverticulum  of,  536;  ganglion  of,  ex- 
cision of,  472. 


A   TEXT-BOOK   ON   SURGERY. 


Median  lithotomy,  663 ;  nerve,  injury  to,  in  dislo- 
cation of  the  elbow,  335. 

Mediastinum,  523. 

Medication  before  operation,  49 ;  in  inflamma- 
tion, GO. 

Medio-tarsal  amputation,  139. 

Medullo-cells  in  tissue  formation,  56. 

Megalopsia,  434. 

Melanotic  carcinoma,  840 ;  sarcoma,  845,  846. 

Membrane,  abscess,  61,  63 ;  mucous,  of  the  tym- 
panum, 440. 

Meninges,  carcinoma  of,  385. 

Meningitis,  syphilitic,  733. 

Meningocele,  385. 

Mercier.     Bxcisor,  671. 

Mercury,  bichloride  of,  as  an  antiseptic,  3 ;  in 
lymphadenitis,  164 ;  in  syphilis,  730. 

Meriwether.     Case  of  aneurism,  331. 

Mesarteritis,  171. 

Mesophlebitis,  165. 

Metacarpal  bones,  dislocations  of  the,  838 ;  ex- 
section,  381 ;  fractures,  304. 

Metacarpo-phalangeal  joints,  exsection  of,  381. 

Metacarpus,  amputations  at  the,  134. 

Metastasis  in  septic  inflammation,  67. 

Metastatic  abscess,  66. 

Metatarsal  bones,  amputation  of,  136 ;  disloca- 

'   tions,  350;  fractures,  323.    • 

Metatarso-phalangeal  joints,  amputation  at  the, 

"    134 ;  arthritis,  366  ;  dislocations,  350. 

Metatarsus,  amputation  of  the,  135,  137. 

Methods  of  dressing  wounds,  1 ;  of  performing 
amputations,  109,  111. 

Metschnikoff.    Phagocytosis,  67. 

Micro-coccus  of  erysipelas,  84. 

Micro-organisms,  causing  infliamraation,  54  ;  of 
blue  pus,  62  :  of  gonorrhoea,  677 ;  of  glanders, 
83 ;  of  putrid  infection,  60 ;  of  syphilis,  717 ; 
of  tetanus,  83. 

Micropsia,  424. 

Middle-ear,  440. 

Middle  finger,  amputation  of,  133. 

Misplaced  testicle,  750. 

Mitchell,  S.  Weir.     Snake-venom,  79. 

Mixed  flaps  in  amputations,  118. 

Mixed  sores,  728. 

Moccasin-snake,  79. 

Modified  circular  flaps,  118. 

Moist  gangrene,  100. 

Molecular  death  of  tissue,  100. 

Moles,  300  ;  of  cheek  and  lip,  455. 

Mollities  ossium,  279. 

Monsel's  solution  for  angeioma,  197  ;  for  haem- 
orrhage after  extraction  of  teeth,  478. 

Monteira.     Case  of  aneurism,  239. 

Montgomery.     Case  of  aneurism,  316. 

Moore.  Fracture  of  clavicle,  393  ;  of  radius  near 
carpus,  303. 

MorbUs'coxsB,  354;  diagnosis,  357. 

Morgagni.     Cataract,  419  ;  hydatid,  775. 


Morgan.     Case  of  aneurism,  227. 

Morphia,  after  operations,  53  ;  in  burns,  93  ;  in 
cystitis.  633 ;  in  ether  narcosis,  26 ;  in  inflam- 
mation 60  ;  in  renal  calculus,  633. 

Mortification,  100. 

Morton.     Spina  bifida,  800. 

Motor-paralysis,  operation  for,  391. 

Mott,  A.  B.    Case  of  aneurism,  316,  333. 

Mott,  Valentine.  Cases  of  aneurism,  218,  323, 
224 ;  case  of  ligation  of  innominate,  237. 

Mott-Heister,  mouth-gag,  27. 

Mouth,  contraction  of,  466  ;  syphilis,  734. 

Mucocele,  406. 

Mucoid  carcinoma,  839. 

Mucous  cysts,  851 ;  membrane  of  tympanum, 
440 ;  patches,  720 ;  surfaces,  iodoform  on,  5. 

Mulberry  calculus,  646. 

Milller.  Cholesteatomata,  848 ;  malignant  angi- 
oma, 197;  pathology  of  tumors,  837. 

Mumps,  470. 

Murray.     Case  of  aneurism,  339. 

Muscae  volitantes,  423. 

Muscles,  artificial,  817. 

Muscular  rheumatism  at  shoulder -joint,  3G7; 
spasm  in  diagnosis  of  hip-joint  dislocation, 
342. 

Musculo-spiral  nerve,  injury  to,  in  dislocations 
of  the  elbow,  335. 

Musket-ball,  91. 

Muslin  bandages,  10. 

Mussey.  Cirsoid  arterial  tumor,  191 ;  operation 
for,  192. 

Mutter.     Plastic  operation  on  the  cheek,  466. 

Mydriatics,  438. 

Myelitis  in  tetanus,  88,  89. 

Myeloplaxes  in  fractures,  381 ;  in  inflammation 
of  bone,  376 ;  in  tissue  formation,  56. 

Myocarditis  syphilitica,  7-24. 

Myoma,  853;  of  the  bladder,  640. 

Myopia,  426,  429. 

Myosin-coagulation  in  gangrene,  101. 

Myxoedema,  495. 

Myxo-lipoma,  852. 

Myxoma,  853  ;  of  the  antrum  of  Highmore,  471 ; 
of  the  bladder,  640 ;  of  the  lower  jaw,  474 ;  of 
the  mamma,  516;  of  the  nose,  443;  of  the 
parotid  gland,  468. 

Nachet.     Trial-glasses  for  testing  vision,  431. 

IsTEevoid  elephantiasis,  196. 

Naevus,  cavernous,  195 ;  of  the  cheek  and  lip, 
455  ;  of  the  head,  383 ;  near  the  eye,  397 ;  pig- 
mentosus,  301 ;  pilosus,  201 ;  vulgaris,  201. 

Naia  tripudians,  79. 

Nail,  ingrowing,  825. 

Narcosis,  chloroform,  25 ;  ether,  26. 

Nares,  fissure  of  the,  444 ;  occlusion,  452  ;  plug- 
ging, 443. 

Nasal  bones,  fractures  of,  288;  pins,  445;  sep- 
tum, lateral  deviation  of,  445. 


INDEX. 


877 


Narrowing  of  ragina,  760. 

Natural  amputations,  107. 

Nebula,  414. 

Neck,   abscess    of,   493 ;    cysts,    493 ;    gunshot- 

-  wounds,  492;  wounds  of,.  491. 

Neoro-biosis.  in  arteries,  177 ;  in  ulcers,  99. 

Necrosis,  100 ;  of  bone,  275 ;  of  calvaria,  after 
nsevus,  197 ;  treatment  of,  278. 

Necrotic  process  in  carbuncle,  98. 

Needle,  43 ;  aneurism,  37 ;  cervix,  764 ;  hernia, 
562 ;  holder,  42,  77 :  Sims's,  holder,  762  ;  hot, 
for  angioma,  197 ;  Peaslee's,  486 ;  surgical, 
43 ;  suture,  77 ;  varicocele,  742 ;  wire  suture, 
43. 

Nelaton,  bjllet-probe,  43  ;  catheter,  633  ;  cirsoid 
tumor,  193 ;  harelip,  459 ;  test-line  for  de- 
formities of  hip,  801 ;  for  fracture  of  femur, 
309 ;  for  morbus  coxae,  356. 

Neoplasms,  8 ;  malignant,  837 ;  non-malignant, 
848 ;  of  the  frontal  sinus,  445 ;  of  the  intestine, 
536;  of  the  larj-nx,  505:  of  the  nose,  443;  of 
the  pharynx,  507 ;  of  the  urethra,  706. 

Nephralgia,  620. 

Nephrectomy,  626. 

Nephritis,  a  cause  of  arteritis,  173. 

Nephrolithotomy,  636. 

Nephrotomy,  636. 

Nerve,  branches  of  fifth,  exsection  of,  473 ;  infe- 
rior dental,  exsection  of,  476. 

Nerves,  suture  of,  in  wounds  of  neck,  491. 

Nettleship.    Pannus,  413 ;  trachoma,  408. 

Neuber.     Bone-drains,  8;  in  amputations,  114. 

Neumeister.     Case  of  aneurism,  318. 

Neuralgia,  facial,  surgical  treatment  of,  473,  476 ; 
of  the  prostate,  676 ;  of  the  rectum,  608 ;  of 
the  shoulder-joint,  diagnosis,  366;  of  sterno- 
mastoideus  muscle,  781. 

Neurectomy,  472,  473. 

Neuroma,  853. 

Neuro-sarcoma,  848. 

Nichols.     Case  of  aneurism,  224. 

Nicolaier.     Tetanus  bacillus,  88. 

Nipple,  abscess  of  the,  513 ;  eczema,  513 ;  epi- 
thelioma, 513  ;  fissure,  513  ;  tumors,  513. 

Nitrate  of  silver  in  prostatorrhcea,  673 ;  in  vagi- 
nitis, 759. 

Nitric  acid,  for  angioma,  197;  in  hospital  gan- 
grene, 105 ;  in  phagedenic  ulcers,  716. 

Nitrogenous  food  in  gangrene,  101. 

Nitrous-oxide  gas,  in  the  after-treatment  of  fract- 
ures, 298 ;  in  extraction  of  teeth,  478. 

Norman.     Case  of  aneurism,  333. 

Nose,  affections  of  the,  443 ;  bifid,  451 ;  calculi, 
443;  deviation  of  septum,  445;  epithelioma, 
445;  epistaxis,  443;  fissure  of,  444;  foreign 
bodies  in,  442 ;  hypertrophy  of,  446 ;  of  the 
mucous  membrane  of,,  443  ;  plastic  operations 
on  the,  446;  plugging  of  the,  442;  polypus, 
443 ;  syphilis,  724. 

Nussbaum.    Case  of  aneurism,  318. 


Nutrition,  before  operations  on  the  abdomen, 
49 ;  in  hospital  gangrene,  105  ;  in  lymphadeni- 
tis, 164;  in  phlebitis,  171. 

Nyctalopia,  424. 

Nyrop.  Boot  for  talipes  valgus,  830;  spring 
brace,  786. 

Oakum,  as  a  dressing  for  ulcers,  99. 

Oblique  flaps  in  amputations,  115. 

Obstruction  of  the  alimentary  canal,  530. 

Obturator  hernia,  555 ;  diagnosis  and  treatment, 
574. 

Occipital  artery,  ligation  of,  250. 

Occlusion,  intestinal,  538;  of  the  alimentary 
canal,  530 ;  of  the  basilar  artery,  183 ;  of  the 
nares,  452. 

O'Dwyer.     Laryngeal  tube,  499. 

CEdema  of  the  glottis,  after  tonsillar  abscess, 
489 ;  of  scrotum,  734. 

CEsophagectomy,  511. 

ffisophagotome,  509. 

ffisophagotomy,  508. 

CEsophagus,  507 ;  carcinoma  of,  511 ;  diverticu- 
la, 513 ;  epithelioma,  511 ;  fistula,  513  ;  foreign 
bodies  in,  507 ;  sounds,  507 ;  stricture,  509 ; 
syphilis,  735  ;  tumors,  511 ;  wounds,  491. 

Ogston.     Operation  for  genu  valgum,  807. 

Oil  of  juniper,  for  catgut,  2. 

Oiled  silk,  9. 

Olecranon,  fractures  of,  299. 

Opacities  of  the  cornea,  436 ;  of  the  lens,  436. 

Open  method  of  treating  amputations,  119. 

Operating  cabinet,  47;  gown,  49;  room,  44; 
stool,  45 ;  tables,  44. 

Operation  for  artificial  anus,  576 ;  for  cleft  pal- 
ate, 478 ;  for  non-union  of  fractures,  324  ;  for 
strangulated  hernia,  566 ;  place  of,  44. 

Operations,  plastic,  of  face,  397,  405,-446,  et  seg. ; 
for  burns,  95 ;  near  the  eye,  397,  405 ;  of  the 
cheek,  465 ;  of  the  lip,  456 ;  of  the  mouth,  466 : 
of  the  nose,  446 ;  surgical,  35  ;  method  of  con- 
ducting, 50,  108,  et  seg. 

Ophthalmia,  gonorrhoeal,  408  ;  neonatorum,  409. 

Ophthalmitis,  sympathetic,  516. 

Ophthalmoscope,  Loring's,  435 ;  mode  of  using, 
435. 

Ophthalmoscopy,  435. 

Opium,  after  lithotrity,  654 ;  in  gangrene,  104, 
105  ;  in  haematuria.  645  ;  in  intestinal  obstruc- 
tion, 533 ;  in  rabies,  82 ;  in  retention  of  urine, 
636 ;  in  suppression  of  urine,  625. 

Opisthotonos,  in  tetanus,  89. 

Optic  nerve,  atrophy  of,  437. 

Optic  neuritis,  434, 436. 

Orchitis,  745 ;  gonorrhoeal,  684 ;  in  mumps,  470 ; 
syphilitic,  735 ;  tuberculous,  747. 

Ordile.     Case  of  aneurism,  216. 

O'Reilly.    Case  of  aneurism,  224. 

Orfila.     Vascular  tumor,  194. 

O'Shaughnessy.     Case  of  aneurism,  216. 


878 


A  TEXT-BOOK  ON  SURGERY. 


Os  innominatum,  fracture  of,  306 ;  hyoides,  fract- 
ure of,  393. 

Osteo-arthritis  of  the  elbow,  367;  of  the  hip, 
353 ;  of  the  knee,  363 ;  of  the  shoulder,  867 ; 
of  the  wrist,  367. 

Osteo-elasis  of  femur,  804,  809. 

Osteo-lipoina,  843. 

Osteoma,  856 ;  of  skull,  385. 

Osteomalacia,  279. 

Osteomyelitis,  376  ;  in  femur,  153. 

Osteo-plastic  operation,  for  tumor  of  antrum  of 
Highmore,  473. 

Osteosarcoma,  197. 

Osteotome,  38. 

Osteotomy  of  femur,  803,  804,  809 ;  of  fore-arm, 
827. 

Ostitis,  275  ;  at  the  hip,  354 ;  caseosa,  376  ;  cause 
of  non-union  after  fractures,  323 ;  fungosa, 
276  ;  of  the  claTicle,  523 ;  of  the  frontal  sinus, 
444 ;  of  the  lower  jaw,  474 ;  of  the  ribs,  515  ; 
of  the  skull,  383;  of  the  spine,  787;  of  the 
sternum,  521 ;  of  the  thorax,  521 ;  of  the  upper 
jaw,  471 ;  osteoplastiea,  376 ;  rarefaciens,  276 ; 
sclerosa,  276 ;  syphilitic,  720,  723 ;  tuberculous, 
276,  353. 

Otis,  P.  N.  Cocaine-tube,  690 :  location  of 
stricture,  689 ;  urethrotome,  693  ;  wire  bougie, 
689. 

Otis,  G.  A.  Statistics  of  shot-wounds  of  the 
face,  896. 

Otitis  media,  440. 

Oval  flaps  in  amputations,  117. 

Ovarian  cysts,  622;  multilocular,  774. 

Ovariotomy,  776. 

Ovary,  abscess  of,  773  ;  carcinoma,  775 ;  cirrhosis, 
773;  cyst-adenoma,  774;  cystic  degeneration 
of,  771 ;  cystic  tumors,  774 ;  dermoid  cysts, 
774;  fibro-rayoma,  776;  hernia  of,  758;  sar- 
coma, 775 ;  solid  tumors,  775. 

Oxalic  acid  for  sponges,  7. 

OziEna,  444;  syphilitic,  444. 

Packing,  as  a  hfemostatic,  in  wounds,  73 ;  tem- 
porary, in  wounds,  74. 

Paget.  Case  of  aneurism,  337;  connective  tissue 
in  wounds,  70 ;  phlebitis,  168,  169. 

Pain,  after  operation,  treated  by  morphine,  58 ; 
in  aneurism,  304  ;  in  gangrene,  100 ;  in  inflam- 
mation, 54,  55. 

Palate,  affections  of  the,  478 ;  cleft  of,  478 ;  op- 
eration  for,  under  cocaine,  23;  instruments 
for,  35 ;  hard,  cleft  of,  481 ;  perforations  of, 
482 ;  tumors  of,  478. 

Pallor  in  gangrene,  100. 

Pancoast.    Case  of  aneurism,  226. 

Pancreas,  586  ;  cyst  of,  587. 

Pannus,  413. 

Papilloma,  848 ;  of  antrum  of  Highmore,  471 ;  of 
the  bladder,  639 ;  of  the  head,  383  ;  of  the  kid- 
ney, 634;  of  the  larynx,  505;  of  the  lip,  455; 


of  the  nipple,  514 ;  of  the  nose,  443 ;  of  the 
tongue,  483  ;  of  the  urethra,  706 ;  of  the  vulva, 
757. 

Papular  syphilide,  730. 

Paquelin.  Cautery,  in  hsemorrhoids,  616 ;  in  op- 
erations on  the  tongue,  483,  485  ;  in  prolapse 
of  the  rectum,  609  ;  in  ranula,  488. 

Paraglobin,  relation  of,  to  stasis,  55. 

Paralysis  of  muscles,  causing  contractures,  830 ; 
of  respiratory  muscles  by  cocaine,  22 ;  of  the 
bladder,  634 ;  of  the  deltoid  muscle,  826 ;  of 
the  serratus  magnus  muscle,  836 ;  syphilitic, 
733. 

Paraphimosis,  683. 

Parker.  Case  of  aneurism,  334,  238 ;  case  of 
ligation  of  subclavia  and  carotid,  257. 

Paronychia,  syphilitic,  733. 

Parotid  gland,  466;  abscess  of,  470;  duct  of, 
466 ;  extirpation  of ;  468,  469 ;  tumors  of,  468. 

Parotitis,  470. 

Partridge.     Case  of  aneurism,  324. 

Passive  motion,  after  exsection  of  hip-joint,  361. 

Pasteur.     Rabies,  81. 

Patches,  mucous,  720. 

Patella,  dislocations  of,  348  ;  fractures,  314. 

Pathogenic  micro-organisms,  60. 

Pathology  of  syphilis,  726. 

Pearly  epithelioma,  848. 

Peaslee.     Needle,  486,  742. 

Peat,  as  an  absorbent  dressing,  9. 

Pedis  dorsalis  artery,  ligation  of,  374. 

Pelletan.     Case  of  aneurism,  226. 

Penis,  706 ;  amputation  of,  709 ;  carcinoma,  707 ; 
herpes,  713  ;  inflammation  of,  706 ;  malforma- 
tions, 706 ;  sarcoma,  710 ;  ulcers,  713 ;  wounds, 
707. 

Peptonized  foods  in  hospital  gangrene,  105. 

Perforation  of  the  antrum  of  Highmore,  471 ;  of 
the  palate,  483. 

Periadenitis  of  neck,  493. 

Periarteritis,  171. 

Perichondroma,  856. 

Perineal  cystotomy,  658  ;  for  wounds  of  blad- 
der, 930 ;  lithotomy,  658  ;  section,  for  stricture 
of  urethra,  697. 

Perineorraphy,  755. 

Perinephritis,  630. 

Perinasum,  laceration  of,  753;  operations  for, 
753  ;  rupture  of,  753. 

Periorchitis  serosa,  735;  diagnosis,  746. 

Periphlebitis,  165. 

Periosteal  elevator,  38. 

Periostitis,  375,  377 ;  of  upper  jaw,  471 ;  syphi' 
litic,  723. 

Peri-rectal  abscess,  596. 

Perispermatitis,  735. 

Perisplenic  abscess,  586. 

Peritoneal  abscess,  579. 

Peritonitis,  578 ;  after  burns,  93 ;  laparotomy 
for,  578. 


INDEX. 


879 


Perityphlitic  abscess,  580. 

Permanent  dressings,  53. 

Permanganate  of  potassa,  for  serpent- wounds,  80. 

Peroneal  aneurism,  231 :  artery,  ligation  of,  372  ; 
muscles,  tenotomy  of,  821. 

Petit.  Arterial  cirsoid  tumor,  192  ;  fracture-box, 
320;  tourniquet,  73. 

Phagedenic  bubo,  715 ;  gangrene,  104 ;  ulcer  of 
penis,  714 ;  ulcer  of  rectum,  600. 

Phagocytes,  67. 

Phalangeal  joints,  dislocation  of,  338. 

Phalanges,  dislocations  of,  338  ;  fracture  of,  305. 

Pharyngeal  artery,  ascending,  ligation  of,  350. 

Pharynx,  507;  abscess  of,  493,  507,  790;  affec- 
tions of,  507 ;  carcinoma,  507 ;  foreign  bodies 
in,  507 ;  retropharyngeal  abscess,  492,  507,  790 ; 
syphilis,  725  :  tumors  of,  507. 

Phenomena  of  inflammation,  54. 

Phimosis,  710;  operation  for,  711. 

Phlebitis,  86,  165 ;  acute,  163. 

Phlebolites,  195,  200. 

Phlegmon  of  fingers,  834 ;  of  hand,  834  ;  of  lip, 
455  ;  of  the  neck,  493 ;  of  the  scrotum,  734. 

Phlegmonous  erysipelas,  86. 

PhlyotsnuliB,  413. 

Phorometer,  433. 

Phosphatic  calculus,  646. 

Phosphorus  disease  of  jaws,  471,  474. 

Pigeon-toe,  834. 

Pigment,  in  the  skin,  201. 

Pilcher.     Fracture  of  radius,  303. 

Piles,  611;  capillary,  618;  chronic,  613;  exter- 
nal, 611 ;  internal,  611,  613;  ligation  of,  614; 
treatment  by  the  actual  cautery,  616  ;  White- 
head's operation  for,  615. 

Pilocarpine,  in  suppression  of  urine,  625. 

Pin,  hare-lip,  458 ;  suture,  76. 

Pinguecula,  410. 

PirogoflE.  Amputation  at  the  ankle,  143;  cases 
of  aneurism,  218,  219,  223;  etherization  per 
rectum,  33;  ligation  of  carotid  for  vascular 
tumor,  192. 

Pitha.     Injections  for  vascular  tumors,  193. 

Pitres.  Cerebral  localization  of  symptoms  of 
motor  paralysis,  389. 

Pityriasis  versicolor,  of  anus,  594. 

Planus  talipes,  821. 

Plaques,  mucous,  720. 

Plasmin,  167. 

Plaster-of- Paris  bandage,  10 ;  in  fracture  of  the 
femur,  311;  of  the  humerus,  296;  of  the  leg, 
321,  323;  of  the  patella,  317;  in  synovitis, 
359,  365 ;  in  ununited  fractures,  324. 

Plastic  operations,  for  burns,  95. 

Plastic  surgery,  95 ;  near  the  eye.  397,  405 ;  of 
the  cheek,  465 ;  of  the  lip,  456 ;  of  the  mouth, 
466 ;  of  the  nose,  446. 

Playfair.     Operation  for  peritonitis,  578. 

Pleuritis  following  burns,  93  ;  following  wounds 
of  the  chest,  524. 


Pleurosthotonos  in  tetanus,  89. 

Plexiform  angioma,  195. 

Plug,  vaginal,  759. 

Plugging  of  the  nares,  442. 

Pneumatocele,  383. 

Pneumonia,  syphilitic,  724. 

Pneumonitis,  following  burns.  93. 

Pneumothorax.  533. 

Poisoned  wounds,  68,  78,  84. 

Polaillon.     Cirsoid  aneurism,  191. 

Poland.     Case  of  aneurism,  337. 

Politzer.     Tympanum  perforator,  440. 

Polydactylus,  832,  839. 

Polypus,  cystic,  607;  fibrous,  of  nose,  443; 
fibrous,  of  rectum,  607  ;  gelatinous,  443  ;  of  the 
larynx,  506  ;  of  the  nose,  443  ;  of  the  rectum, 
607 ;  villous,  of  rectum,  607. 

Pope.     Tarantula-bite,  80. 

Popliteal  artery,  aneurism  of,  331 ;  ligation  of, 
272. 

Porro's  operation,  768.    ■ 

Porta.     Case  of  aneurism,  218. 

Porter.     Case  of  aneurism,  336. 

Port-wine  mark,  301 ;  of  head,  383. 

Position  of  assistants  during  amputation,  110 ;  of 
limb  in  gangrene,  101. 

Posterior  auricular  artery,  ligation  of,  353 ;  tibial 
artery,  ligation  of,  373. 

Posterior  curvature  of  the  spine,  787. 

Posthitis,  678,  682. 

Posture,  in  the  treatment  of  aneurism,  210. 

Potass,  bromide  of,  for  chordee,  680  ;  citrate  of, 
for  renal  calculus,  623 ;  permanganate  of,  for 
bleaching  sponges,  7 ;  iodide,  vide  iodide. 

Pott's  disease  of  the  spine,  787;  diagnosis,  790; 
fracture,  318. 

Poultices  in  carbuncle,  99 ;  in  furuncle,  97 ;  in 
inflammation,  60. 

Powers.  Treatment  of  dislocation  of  the  hume- 
rus, 338. 

Preparation  of  antiseptic  material,  1 ;  of  attend- 
ants, etc.,  for  operation,  49 ;  of  patients,  for 
narcosis,  26 ;  moral,  48 ;  physical,  49. 

Prepuce,  adhesions  of,  713;  amputation,  711; 
dilatation,  713 ;  divulsion,  713 ;  incision,  713 ; 
phimosis,  710. 

Presbyopia,  433. 

Pressure  symptoms,  in  aneurism,  311  et  seg. 

Primary  amputation,  107. 

Probang  lor  oesophagus,  508. 

Probe,  bullet,  43 ;  >relaton's,  43. 

Productive  ostitis,  276. 

Profunda  femoris  artery,  aneurism  or,  231 ;  liga- 
tion of,  371. 

Projectiles,  91  ;  varieties  of,  91. 

Prolapse  of  the  rectum,  608 ;  of  the  uterus,  760. 

Proliferation  of  cells  in  endarteritis,  175 ;  in  in- 
flammation, 55. 

Prostatic  syringe,  673. 

Prostatitis,  665. 


880 


A  TEXT-BOOK   ON  SURGERY. 


Prostate  body,  665 ;  calculi  of  the,  675 ;  carci- 
noma, 674;  concretions,  675 ;  dilatation,  668  ; 
excision  of  hyperti'ophy  of,  671 ;  exploration, 
669 ;  hypertrophy,  666 ;  neuralgia  of,  676 ;  sar- 
coma, 675 ;  tuberculosis,  674. 

Prostatorrhcea,  673. 

Prostration  in  hospital  gangrene,  105. 

Protection  of  field  of  operation,  50 ;  of  patients 
during  operation,  50. 

Protective,  9 ; ,  for  burns,  93 ;  in  amputation 
dressings,  115 ;  on  wounds,  74. 

Protiodide  in  lymphadenitis,  164;  in  syphilis, 
731. 

Pruritus  of  the  anus,  593 ;  of  the  vulva,  758. 

Psoas  abscess,  783,  790. 

Psoriasis,  syphilitic,  721.  . 

Pterygium,  410.        i 

Ptomaines,  action  of  iodoform  on,  5 ;  cause  of 
septicasraia,  66 ;  in  tetanus,  88. 

Pubes,  fracture  of,  307. 

Pubic  dislocation  of  the  hip-joint,  339,  343,  345. 

Pudic,  internal,  ai'tery,  ligation  of,  267. 

Pulsation  in  aneurism,  204. 

Pulse  in  tetanus,  89. 

Puncture  of  the  bladder,  637;  multiple,  of  the 
testicle  for  epididymitis,  884,  745,  746;  for  or- 
chitis, 684. 

Punctured  wounds,  68. 

Pure  water  for  continuous  irrigation  in  amputa- 
tion, 120. 

Pus,  61;  basin,  48;  blue,  63;  corpuscles,  61 ;  in 
the  urine,  643 ;  liquor  purls,  61. 

Pustular  syphilide,  731. 

Pustule,  malignant,  83. 

Putrefaction,  in  gangrene,  101. 

Putrid  surfaces,  iodoform  on,  5. 

Pyasmia,  60,  66;  after  ligature  of  arteries,  175; 
metastatic  abscess  of,  67. 

Pyelitis,  620. 

Pylorectomy,  526. 

Pylorus,  essection  of,  526 ;  stricture  of,  535. 

Pyogenic  membrane,  536. 

Pyrogallic  acid  in  lupus,  454. 

Quilled  suture,  75. 

Quinia,  in  dissection  wounds,  84 ;  in  erysipelas, 

87;  in  inflammation,  60;  in  phlebitis,  171;  in 

tonsillitis,  489. 

Rabid  animals,  wounds  by,  81. 

Rabies,  81,  89. 

Racemose  adenoma,  849. 

Rachitis,  279,  804,  809 ;  treatment  of,  by  osteoto- 
my, 837. 

Radial  artery,  aneurism  of,  337;  ligation  of, 
263. 

Radical  cure  of  hernia,  559. 

Radio-carpal  dislocation,  136. 

Radius,  fractures  of,  300;  subluxation  of  head 
of,  324. 


Radius  and  ulna,  dislocations  of,  at  elbow, 
335. 

Railway  fracture,  818. 

RansohofE.    Case  of  aneurism,  219. 

Ranvier,  vide  Cornil.  Formation  of  capillaries 
in  wounds;  69. 

Ranula,  488. 

Rattlesnake-bite,  79. 

Rectal  puncture  of  the  bladder,  638. 

Rectal  urinary  fistula,  703. 

Rectocele,  760. 

Rectum,  abscess  of,  596 :  administration  of  ether 
by  the,  36, 32 :  ascarides  in,  595  ;  atresia  of,  591 ; 
carcinoma,  605  ;  chancre,  601 ;  chancroid,  600 ; 
dilatation,  605;  epithelioma,  536,  605;'  en- 
cephaloid,  605;  exsection,  606;  fistula;  ,595, 
703  ;  foreign  bodies  in,  595;  lupoid  ulcer,:600; 
neoplasms  of,  605 ;  neuralgia,  608 ;  phagedenic 
ulcer  of,  600 ;  polypus,  608 ;  prolapse,  608 ; 
treatment,  609;  scirrhus,  605;  speculum,  595; 
stricture,  601,  603;  syphilis,  600,  725;  ulcera- 
tions, 600. 

Rectotomy,  604. 

Redness  in  inflammation,  54. 

Reef-knot,  53. 

Reeves.  Operation  for  genu  valgum,  807 ;  shoe 
for  talipes,  818;  snap-finger,  833;  suspensory 
cradle,  799 ;  talipes  valgus,  830. 

Refraction  of  eye,  436. 

Regional  surgery,  383.  , 

Reichert.  Coagulation  of  blood,  168;  serpent- 
venom,  79. 

Removal,  vide  excision,  extirpation. 

Renal  calculus,  630,  633,  626,  646  ;  colic,  623 ; 
cysts,  623. 

Repair  of  tissues  in  infiammation,  54,  56 ;  in  ve-. 
nous  inflammation,  167  ;  in  wounds,  70. 

Resection,  r'l'tZe  excision. 

Resolution  of  tissue,  56. 

Respiration,  artificial,  in  ether  narcosis,  30 ;  Syl- 
vester's method  of,  31. 

Rest  in  aneurism,  205  ;  in  inflammation,  56  ;  in 
periostitis,  277;  in  phlebitis,  170 ;  in  synovitis, 
365. 

Restoration  of  eyelids,  405. 

Resuscitation  after  ether  and  chloroform  narco- 
sis, 31. 

Retention  of  urine,  635 ;  from  nerve  lesions,  635 ; 
from  paralysis,  635 ;  from  spasm,  635 ;  from 
stricture  of  the  urethra,  635. 

Retina,  433. 

Retinitis,  433,  437 ;  pigmentosa,  434. 

Retractors,  36  ;  in  amputations,  112. 

Retroperitoneal  abscess,  581. 

Retropharyngeal  abscess,  498,  507,  790. 

Retrosternal  abscess,  531. 

Reverse  in  spiral  bandage,  11. 

Reynders.  Apparatus  for  torticollis,  781 ;  sus- 
pension apparatus,  792. 

Rhabdomyoma  of  the  kidney,  .634. 


INDEX. 


881 


Rheumatic  arteritis,  187 ;  myositis  at  hip  ;  diag- 
nosis, 357. 

Rheumatism  a  cause  of  arteritis,  173 ;  gonor- 
rhceal,  685. 

Rhigolene  as  a  local  anaesthetic,  24. 

Rhiiiolites,  443. 

Rhinoplasty,  446 ;  Hindoo  method,  448 ;  method 
of  Dieffenbach,  448  ;  of  Pabrizzi,  450 :  of  Koe- 
nig,  448  ;  of  Labat,  448  :  of  Langenbeck,  449  ; 
of  Linhart,  448 ;  of  Wutzer,  450 ;  partial, 
451. 

Riberi.    Operation  on  Steno's  duct,  467. 

Ribs,  dislocation  of,  350 ;  excision,  523 ;  fract- 
ures, 305,  523  ;  ostitis,  521. 

Richardson.     Atomizer,  24. 

Rickets,  279. 

Riegner.  Case  of  ligation  of  common  carotid, 
243. 

Rifle-proieetiles,  91. 

Rigen.    Case  of  aneurism,  216. 

Rigors  in  inflammation,  56. 

Rindfleisch.     Cavernous  tumors,  196. 

Ring-flnger,  amputation  of,  123. 

Robert.  Ligation  of  carotid  lor  vascular  tumor, 
193. 

Roberts.    Operation  on  septum  of  nose,  445. 

Robertson.    Ectropion,  400. 

Robin.     Cirsoid  arterial  tumor,  190. 

Robinson.  Carbuncle,  98 ;  lupus  erythematosus, 
454. 

Rodent  ulcer  of  rectum,  600. 

Rodgers.  Case  of  aneurism,  234 ;  case  of  liga- 
tion of  subclavian,  257. 

Rodgers  and  Van  Buren.  Ligation  of  carotid 
for  vascular  tumor,  192. 

Rokitansky.  Cavernous  tumors,  196 ;  diverticula 
of  oesophagus,  513 ;  multilocular  cyst  of  ovary, 
774. 

Rongeur,  39. 

Rossi.    Case  of  aneurism,  317. 

Rotary  lateral  curvature  of  the  spine,  783. 

Round-celled  epithelioma,  842 ;  sarcoma,  844, 
846. 

Rubber,  action  of  sublimate  on,  5 ;  drains,  8 ; 
operating  gown,  50  ;  tissue,  9  :  tubing  for  ap- 
plication of  cold  in  inflammation,  60 ;  ^-ulcan- 
ized  handles  for  instruments,  35. 

Rupia,  syphilitic,  723. 

Rupture  of  abdominal  muscles,  586  ;  of  abdomi- 
nal organs,  587 ;  of  the  bladder,  630 ;  of  the 
oesophagus,  507 ;  of  the  perinEeum,  752 ;  opera- 
tion for,  753  ;  primary,  755  ;  secondary,  756  ; 
of  the  posterior  commissure  of  the  vulva,  573 ; 
of  the  spleen,  585. 

Sacculated  aneurism,  303. 
Sacrum,  fracture  of,  306. 
Saenger.    Hysterectomy,  766. 
Saline  solutions  for  intravenous  injection,  78. 
Salivary  calculus,  466 ;  fistula,  466. 
56 


Salpingitis,  770. 

Sandal-wood,  oil  of,  for  gonorrhoea,  683. 

Sands.  Case  of  aneurism,  314;  ligation  of  ca- 
rotid, 847  ;  oesophagotome,  509 ;  treatment  of 
external  iliac  aneurism,  230. 

Santonin  for  Billharzia  hajmatobia,  645. 

Sarcoma,  843 ;  diagnosis,  840 ;  of  antrum  of 
Highmore,  471 ;  of  bladder,  640 ;  of  dura  ma- 
ter, 385;  of  intestine,  536;  of  kidney,  624;  of 
larynx,  506 ;  of  lower  jaw,  474 ;  of  mammary 
gland,  517;  of  oesophagus,  511;  of  ovary,  775; 
of  parotid  gland,  468  ;  of  penis,  710 ;  of  pros- 
tate, 675;  of  testicle,  749;  of  thyroid  gland, 
494, 497.  ' 

Saltier.    Case  of  intraorbital  aneurism,  333. 

Savage.     Operation  for  peritonitis,  578.  ' 

Sawdust  as  an  absorbent  dressing,  9. 

Saws,  37,  39;  use  of,  in  amputations,  113. 

Sayre.  Apparatus  for  knock-knee,  807 ;  artifi- 
cial muscles  for  torticollis,  780 ;  bandage  for 
fracture  of  clavicle,  337 ;  clavicle,  fracture  of, 
392 ;  bandage  for,  327 ;  double  hip-splint, 
801 ;  exseotion  of  hip,  368 ;  halux  valgus,  823 ; 
jacket,  plaster-of- Paris,  792 ;  Jury  mast,  791, 
795 ;  osteotomy  of  femur,  803 ;  periosteal  ele- 
vator, 881 ;  polydactylus,  823 ;  splint  for  mor- 
bus coxae,  359 ;  talipes  calcaneus,  814 ;  talipes 
equinus,  811 ;  talipes  varus,  817. 

Scalds,  93. 

Scale  for  urethral  instruments,  698. 

Scaling  syphilide,  721. 

Scalp,  abscess  of,  383 ;  cysts,  383 ;  tumors,  383 ; 
cystic,  383 ;  fatty,  383. 

Scalpels,  35 ;  method  of  holding,  50. 

Scalloped  gouge,  38. 

Scapula,  533 ;  amputation  of,  134 ;  excision,  134, 
538 ;  fractures,  394. 

Scapular  artery,  posterior,  ligation  of,  356. 

Scarification,  57 ;  in  inflammation,  57. 

Scarpa.  Ligation  of  arteries,  189 ;  shoe  for  tali- 
pes varus,  818. 

Schmidt.     Coagulation  of  blood,  168,  203. 

Schroeder.  Hysterectomy  for  fibro  -  myomata,. 
769. 

Schuh.    Injection  for  vascular  tumors,  193. 

Schiitz.     Glanders,  88. 

Sciatic  artery,  aneurism  of,  380 ;  ligation  of, 
367. 

Seirrhus,  839 ;  of  the  bladder,  640 ;  of  the  mam- 
mary gland,  518 ;  of  the  rectum,  605.  \ 

Scissor-clamp  forceps,  41. 

Scissors,  43 ;  dressing,  43. 

Scleritis,  415. 

Sclerotica,  415. 

Scoliosis,  779. 

Scoop,  urethral,  701. 

Scoparius,  in  suppression  of  urine,  635. 

Scorpion-venom,  80. 

Scott.     Case  of  aneurism,  318. 

Scraping-out  for  hospital  gangrene,  105. 


882 


A  TEXT-BOOK  ON  SURGERY. 


Scrofulous  dyscrasia,  163. 

Scrotal  clamp,  743. 

Scrotum,  733 ;  angioma  of,  734 ;  contusion,  734 
cysts,  734;  eczema,  734;  elephantiasis,  734 
epithelioma,  735;  erysipelas,  734;  fistula,  735 
gangrene,  734  ;  haematoma,  735  ;  oedema,  734 
phlegmon,  734;  wounds,  733. 

Sebaceous  cysts,  850 :  near  the  eye,  398. 

Secondary  amputations,  107. 

Section,  Csesarean,  766;  perineal,  697;  trochan- 
teric of  femur,  803. 

Sedillot.  Cheiloplasty,  465 ;  method  of  amputat- 
ing leg,  148. 

Selden.  Case  of  fracture  of  neck  of  femur, 
307. 

Senile  gangrene,  103. 

Senn.  Hydrogen  gas  for  diagnosis  of  intestinal 
lesion,  588 ;  intestinal  anastomoses,  539,  546. 

Separation  of  epiphysis  of  humerus,  397. 

Sepsis  rendering  delay  in  operating  danger- 
ous, 49. 

Septic  fever,  54. 

Septicaemia,  60,  66 ;  treatment  of,  67. 

Septiosemic  symptoms  in  hospital  gangrene, 
105. 

Septum  of  nose,  lateral  deviation  of,  445. 

Sequestrum,  375 ;  forceps,  39. 

Serous  cysts,  851. 

Serpent-bites,  78 ;  venom,  toxicity  of,  78. 

Sexton.  Ear-hook,  489 ;  forceps,  439 ;  probe, 
438 ;  snare,  439. 

SchafEer.    Spinal  brace,  306,  791 ;  figure,  795. 

Shells,  90. 

Sheppard.  Statistics  of  amputation  at  hip, 
159. 

Shook,  93,  587;  after  gunshot-wounds,  93 :  symp- 
toms and  treatment  of,  92. 

Shoulder-cap,  in  fracture  of  the  humerus,  397. 

Shoulder-joint,  amputation  at,  133;  ancliylosis, 
836  ;  disarticulation,  133 ;  dislocation,  337 ; 
exsection,  376 ;  synovitis,  366. 

Siehels.    Iris-knife,  411. 

Silk,  1 ;  for  sutures,  3. 

Silk-worm  gut,  1 ;  for  cleft-palate  operations, 
480. 

Silver  fork  deformity  of  wrist,  303. 

Silver  wire  suture,  1,  75 ;   in  fracture  of  jaw, 

*391. 

Simes.    Phlebitis,  169 ;  syphilitic  arteritis,  183. 

Sims,  H.  Marion-,  vide  Marion. 

Sims's  fork  for  silver  sutures,  763 ;  glass  tube  for 
drainage  of  abdominal  cavity,  589,  769 ;  glass 
vaginal  plug,  759  ;  knife-holder,  765  ;  needle- 
forceps,  762  ;  rectal  speculum,  595 ;  scissors, 
42;  skewer-shields,  770;  speculum,  762;  sut- 
ures in  vesico-vaginal  fistula,  713. 

Simple  ulcer  of  penis,  713. 

Sinapisms,  in  infiammation,  60;  in  pyelitis,  621. 

Sinus,  frontal,  abscess  of,  384 ;  of  scrotum,  735. 

Sldn-flap,  116,  139,  146. 


Skin-grafting,  94 ;  in  burns.  94. 

Skull,  carcinoma  of,  384 :  depression  of,  285 ; 
encephalocele,  385 ;  exostosis,  385;  fractures, 
286 ;  gunshot-wounds,  887 ;  meningocele,  385 ; 
net-bandage  for,  21 ;  osteoma,  385 ;  ostitis, 
383;  paracentesis,  894;  penetrating  wounds, 
387 ;  periostitis,  383 ;  pneumatocele,  383 ;  sar- 
coma, 385 ;  wounds,  886. 

Sliding  of  skin  for  burns,  85 ;  of  palate,  for  fis 
sure,  481. 

Smith.     HEEmorrhoidal  clamp,  616. 

Smith,  Stephen.  Amputation  at  knee,  150 ;  of 
leg,  146 ;  of  Syme,  141. 

Smyth.     Cases  of  aneurism,  238,  328. 

Snake-bites,  78 ;  treatment  of,  80. 

Snare,  Sexton's,  439. 

Snap-finger,  833. 

Snellen.     Entropion,  404 ;  test  types,  431. 

Soap,  green,  in  lupus,  454. 

Solid  flaps,  109. 

Solution,  antiseptic,  3 ;  boric-acid,  3 ;  carbolic- 
acid,  3 ;  of  iodoform  and  ether,  5 ;  oxalic-acid, 
7 ;  salicylic-acid,  8,  5 ;  salicylico-boric,  5. 

Sore  nipples,  518. 

Sound,  cupped,  673 ;  oesophageal,  507 ;  steel  ure- 
thral, 698. 

South.    Case  of  aneurism,  329. 

Southam.    Babies,  88. 

Spasm  of  the  sphincter  ani,  603. 

Special  amputations,  130. 

Speculum,  rectal,  595  ;  urethral,  706. 

Spence.     Erectile  tumor,  198,  194. 

Spermatorrhoea,  673,  674. 

Spheno-maxillary  fossa,  wounds  of,  396, 

Spherical  aneurism,  302. 

Sphincter  ani,  divulsion  of,  599. 

Spica  bandage,  15. 

Spina  bifida,  799. 

Spinal  column,  deformities  of,  779. 

Spinal  cord,  syphilis  of,  723. 

Spindle-celled  sarcoma,  844,  846. 

Spine,  abscess  of,  789 ;  anterior  curvature,  786  ; 
bifid,  799  ;  dislocations,  350  ;  lateral  curvature, 
779,  782  ;  posterior  curvature,  787 ;  rotary  lat- 
eral curvature,  783. 

Spiral  bandage,  11. 

Spleen,  585 ;  abscess  of,  585 ;  cyst,  586 ;  excision, 
586 ;  hernia,  586  ;  rupture,  585 ;  syphilis,  735 ; 
wandering,  586. 

Splenectomy,  586. 

Splenic  abscess,  585. 

Spondylitis,  787. 

Sponge-holders,  43. 

Sponges,  compression  with,  during  operation,  52  ; 
disinfecting  of,  3,  6  ;  manipulation  of,  110. 

Spoons,  sharp,  38. 

Spray,  carbolic-acid,  4;  before  operations,  44; 
ether,  24;  machine,  4. 

Squibb.     Ether,  36. 

Stalactites,  857 ;  in  fractures,  283. 


INDEX. 


883 


Stalagmites,  856, 

Staphylococcus  pyogenes,  60. 

Staphyloma  of  the  cornea,  413. 

Staphylorraphy,  479. 

Starr.     Symptoms  in  brain  lesions,  389. 

Stasis,  in  the  blood  -  current,  in  inflamma- 
tion, 55. 

Statistics  of  amputations,  107 ;  at  hip,  159 ;  of 
operations  for  aneurisms,  221,  334. 

Staton.     Case  of  gastrostomy,  511. 

Steel  sounds.  698. 

SteDate  fracture  of  patella,  314. 

Steno's  duct,  466. 

Sternberg.    Poison  of  human  saliva,  81. 

Stemo-mastoid  muscle,  neurectomy,  781 ;  tenoto- 
my of,  781. 

Sternum,  exsection  of,  521 :  fractures  of,  305. 

Stevens's  phorometer,  433. 

Stewart.    Exsection  of  intestine,  569. 

Stimson.  Case  of  aneurism,  217;  fracture  of 
femur,  at  neck,  307 ;  through  trochanters, 
812. 

Stimulation,  after  gunshot-wounds,  92  ;  guarded, 
after  operations,  58  ;  in  gangrene,  102 ;  in  hos- 
pital gangrene,  105. 

Sting  of  insects,  81. 

Stokes.    Case  of  aneurism,  229. 

Stomach,  affections  of,  525 ;  exsection  of,  526 ; 
foreign  bodies  in,  527  ;  syphilis  of,  725. 

Stone  in  the  bladder,  645 ;  in  females,  664 ;  li- 
thotomy, for,  654 ;  lithotrity  for,  650. 

Stool,  operating,  45. 

Strabismus,  425. 

Strangulated  hernia,  565 ;  operation  for,  566. 

Strangulation  of  the  intestine,  535. 

Streptococcus  pyogenes,  60. 

Stretching  nerves  in  tetanus,  90. 

Stricture  of  the  intestine,  536 ;  of  the  oesophagus, 
509 ;  of  the  pylorus,  525 ;  of  the  rectum,  601, 
602;  of  the  urethra,  677,  687;  treatment  of, 
693  ;  at  the  meatus,  691. 

Strychnia  in  tetanus,  89. 

Stye,  899. 

Styles,  melanotic  n»Tus,  197. 

Styptic  cotton,  73. 

Subacetate  of  lead  in  synovitis,  853;  in  ulcers 
of  the  penis,  716. 

Subclavian  artery,  aneurism  of,  222 ;  ligation  of, 
353,  256,  258 ;  for  aortic  aneurism,  313,  333 : 
for  dislocation  of  humerus,  333 ;  synopsis  of 
cases  of,  224. 

Sublimate,  action  of,  on  rubber.  5  ;  a  preventive 
of  hospital  gangrene,  105;  for  irrigating  ab- 
scesses, 66  ;  gunshot-wounds.  92  ;  wounds,  74 : 
for  poultices,  60  ;  gauze.  9  ;  for  ulcers.  99  ;  in 
amputations,  109,  114;  in  gangrene,  102;  in 
ostitis,  378  ;  solutions,  8,  4,  48. 
Sublingual  gland,  swelling  of,  in  epithelioma  of 

lip,  453. 
Subluxation  of  the  head  of  the  radius,  334. 


Submaxillary  glands,  470 ;  extirpation  of,  470 ; 
swelling  of,  in  epithelioma  of  lip,  453. 

Subperiosteal  operation  on  lower  jaw,  474. 

Subtrochanteric  section  of  femur,  803. 

Suction  for  cataract,  433  ;  in  dissection  wounds, 
84 :  in  snake-bites,  80. 

Sugar  in  the  urine,  643. 

Superior  maxiUa,  vide  jaw. 

Superior  thvroid  artery,  ligation  of,  248. 

Supernumerary  finger.  829 ;  testicle,  750. 

Suppression  of  urine,  619,  624 :  diagnosis,  635. 

Suppuration,  60 ;  in  inflammation,  56 ;  of  hip- 
joint,  860 ;  of  knee,  863. 

Suprapubic  cystotomy,  654,  657,  664 ;  for  vesieo- 
vagina  fistula.  761;  in  females,  664;  puncture 
of  the  bladder,  637.  670. 

Supra-scapular  artery,  ligation  of.  256. 

Surgical  dressings,  1 ;  method  of  applying,  53 ; 
operations,  35. 

Suspension  apparatus,  792. 

Suspensory,  683. 

Sutton.  Intermediate  suture  in  exsection  of  the 
intestine,  .542. 

Sutures,  1 ;  antiseptic,  2,  3  ;  continuous,  75 ; 
cross-,  76 ;  Czerny's  528,  542 ;  double-needle, 
76;  during  operation,  48;  in  abdominal  sec- 
tion, .545:  in  amputations,  114;  interrupted. 
75 ;  intestinal.  528 ;  in  wounded  intestine,  543 ; 
in  wounds.  74 ;  in  wounds  of  the  neck,  491 : 
Lembert's,  528,  542,  598 ;  mattress,  75  ;  needles 
for,  77 ;  of  nerves,  491 ;  pins  for,  76  ;  quilled, 
75 ;  silver  wire,  3,  75. 

Swanzy.  Cataract,  419  ;  conjunctivitis,  408  ; 
ectropion,  401 ;  eczema  of  lids,  405 ;  herpes 
corneie,  412. 

Swelling,  in  gangrene,  101 ;  in  inflammation.  54 

Sylvester.  Method  of  artificial  respiration,  31, 
491 :  for  foreign  body,  503. 

Symblepharon.  400. 

Syme.     Amputation  at  the  ankle,  139. 

Symptoms  of  inflammation,  56. 

Synchisis,  423. 

Syncope  from  haemorrhage,  77;  in  ether  nar- 
cosis, 32. 

Syndactylus.  822.  839. 

Syndesmitis,  351. 
.  Synechia.  415 ;  anterior,  414. 

Synovitis,  351  ;  in  dislocations,  325  ;  of  the 
"ankle,  364;  of  the  elbow,367;  of  the  hip,  356; 
of  the  knee,  362  ;  of  the  shoulder,  366 ;  of  the 
wrist,  368 ;  symptoms  of,  853  ;  syphilitic,  734. 

Syphilides,  730. 

Syphilis.  717 ;  a  cause  of  arteritis,  173 ;  diagnosis 
of,  728;  inherited,  733;  symptoms  of,  733; 
occlusion  of  basilar  artery  in,  182 ;  of  jaw, 
471 ;  of  mammary  gland,  515 ;  of  nose,  446 ; 
of  rectum,  600 ;  of  tongue,  483  :  of  vulva,  757 ; 
pathology  of,  726;  primary.  718,  728;  prog- 
nosis of,  729;  secondary,  720;  tertiary,  723; 
transmissibility  of,  732;  treatment  of,  730. 


A  TEXT-BOOK  ON  SURGERY. 


Syphilitic  adenitis,  719 ;  arteritis,  171, 181 ;  chan- 
cre, 717;  phlebitis,  168,  169;  ulcers  of  the 
penis,  717,  719. 

Syringe,  debris,  661 ;  for  urethra,  614 ;  prostatic, 
611. 

Szamann.     Transfusion,  78. 

Szymanowski.     Urethra  fistula,  703. 

Table,  operating,  44. 

Taenia  echinococcus,  vide  hydatid. 

Tait.  Hysterectomy,  766,  769;  operation  for 
peritonitis,  578. 

Talipes  calcaneus,  813 ;  cavus,  821 ;  equinus, 
811 ;  planus,  831 ;  valgus,  819 ;  varus,  814. 

Tamponade  of  nares,  287. 

Tannic  acid  in  prostatitis,  673. 

Tapping  of  ventricles  of  the  brain,  394. 

Tarantula-venom,  81. 

Tarsal  bones,  amputation  of,  138 ;  dislocation  of, 
350 ;  excision,  138 ;  fracture,  323. 

Tarso-metatarsal  joints,  amputation  at,  135, 136 ; 
arthritis,  366. 

Tarsoraphy,  400. 

Tarso-tibial  amputation,  141. 

Tarsotomy,  818. 

Tarsus,  amputation  through  the,  138. 

Taylor.     Spinal  brace,  306,  791. 

Taxis,  on  strangulated  hernia,  566. 

Teale.  Method  of  amputation,  148 ;  operation 
,  for  symblepharon,  400. 

Teeth,  477 ;  extraction  of,  477. 

Telangiectasis,  195 ;  of  larynx,  506. 

Temperature,  bodily,  in  tetanus,  89. 

Temporal  artery,  ligation  of,  253. 

Temporary  packing  in  wounds,  74. 

Tenaculum,  37. 

Tendo  Achilles,  division  of,  811,  818. 

Tendons,  inflammation  of,  351,  365,  368. 

Tenesmus  of  the  bladder,  638. 

Tenotomy  in  club-hand,  838 ;  in  talipes  equino- 
varus,  818 ;  in  torticollis,  781 ;  of  eye-muscles, 
435 ;  graduated,  435  ;  of  peronei  muscles,  831 ; 
.  of  tendo  Achilles,  811,  818. 

Testicle,  745;  abscess  of,  746;  adenoma,  748; 
carcinoma,  749  ;  cysts,  748 ;  enohondroma, 
748  ;  excision,  749  ;  hernia  of  tubules  of, 
745 ;  hydrocele,  encysted,  of,  738 ;  incarcer- 
ated, 557 ;  inflammation,  745  ;  malposition, 
750;  removal,  749;  retained,  750;  sarcoma, 
749 ;  syphilis,  735 ;  tuberculosis,  747 ;  wounds, 
745. 

Testing  vision  for  glasses,  431. 

Tetanus,  88. 

Textor.  Disarticulation  at  caleaneo-astragaloid 
joint,  139. 

Thecitis,  351,  368;  diagnosis,  865. 

Thermo-oautery,  vide  Paquelin. 

Thiersch's  method  of  grafting,  95;  salicylico- 
boric  solution,  5  ;  in  vaginitis,  758. 

Thigh,  bandage  for,  16 ;  amputation  of,  152. 


Thompson.  Continuous  dilatation  of  strict- 
ure of  urethra,  695  ;  evacuator,  653  ;  hsematu- 
ria,  644 ;  lithotrite,  651  ;  method  of  locating 
htemorrhage  in  urinary  tract,  645 ;  searcher, 
648. 

Thomson.  Case  of  aneurism,  223 ;  color-blind- 
ness, 424. 

Thorax,  533 ;  abscess  of  wall  of,  531 ;  bandage, 
17 ;  foreign  bodies,  534 ;  gunshot-wounds,  523 ; 
wounds,  523. 

Thrombosis,  arterial,  188,  189;  causes  of,  190; 
in  inflammation,  61,  67. 

Thrombus,  in  arteries,  190 ;  in  veins,  167. 

Thumb,  amputation  of,  121 ;  disarticulation,  131, 
123 ;  at  metacarpal  joint,  125. 

Thyroid  artery,  ligation  of,  359 ;  axis,  ligation  of, 
355 ;  body,  493  ;  cysts  of,  494. 

Thyroidectomy,  496. 

Thyrotomy,  498,  506. 

Tibia,  dislocation  of,  at  ankle,  348 ;  at  knee,  347 ; 
fractures,  318. 

Tibial  artery,  aneurism  of,  331 ;  anterior,  ligation 
of,  273 ;  posterior,  ligation  of,  372. 

Tibialis  muscles,  tenotomy  of,  818. 

Tibio-tarsal  amputation,  142. 

Tiemann.  Aspirator,  637  ;  Shaffer's  brace,  797 ; 
tonsillotome,  490. 

I'illanus.    Case  of  aneurism,  316. 

Tillaux.     Cirsoid  aneurism,  190. 

Toad-venom,  80. 

Toes,  amputation,  134 ;  bandage  for,  15 ;  de- 
formities, 884 ;  syphilis,  726. 

Toldt.    Structure  of  arteries,  173. 

Tongue,  483 ;  abscess  of,  483 ;  adhesion,  489 ; 
atrophy,  483;  bifid,  489;  controlling  haemor- 
rhage from,  during  operations  on,  486  ;  cysts, 
483 ;  excision,  485 ;  hypertrophy,  483 ;  wounds, 
483. 

Tongue-tie,  489. 

Tonsillitis,  489. 

Tonsillotome,  490. 

Tonsils,  489 ;  abscess  of  the,  489 ;  carcinoma, 
490 ;  excision,  490 ;  hypertrophy,  490 ;  inflam- 
mation, 489 ;  sarcoma,  490. 

Torticollis,  779 ;  tenotomy  in,  781. 

Tortion  of  arteries,  73. 

Tourniquet,  elastic,  41 ;  emergency,  73 ;  for  pro- 
longing cocaine  anfesthesia,  23 ;  method  of 
haemostasis  with,  51 :  Petit's,  73. 

Toxicity  of  serpent-venom,  78,  79. 

Toxicophis,  79. 

Trachea,  foreign  bodies  in,  501 ;  neoplasms  of 
the,  505. 

Tracheotomy,  499 ;  for  foreign  body,  502 ;  for 
glossitis,  482  ;  high  operation  of.  500 ;  in  ether 
narcosis,  31 ;  in  excision  of  the  tongue,  488 ; 
low  operation,  501. 

Trachoma,  408. 

Transfixion,  for  angioma,  197;  in  forming  flaps, 
109,  116;  in  hip- joint  amputation,  155. 


INDEX. 


885 


Transfusion  of  blood,  77 ;  apparatus  for,  78 ;  for 
syncope,  77 ;  in  ether  narcosis,  27. 

Transplantation  of  skin,  era  masse,  96 ;  for  burns, 
94. 

Transverse  cervical  artery,  ligation  of,  355. 

Traumatic  fever,  60;  phlebitis,  170. 

Trays  for  instruments,  46,  48. 

Treatment  of  inflammation,  56  ;  wounds,  70. 

Tremor  in  aneurism,  304. 

Trendelenburg.  Compression  of  iliac  artery,  154 ; 
tracheal  canula,  505 ;  T-shaped  drainage-tube, 
656. 

Trephining,  in  depressed  fracture  of  skull,  385 ; 
in  injuries  of  the  head,  386 ;  in  ostitis,  378 ; 
instruments  for,  386;  of  antrum  maxillare, 
389 ;  of  frontal  sinus,  445 ;  of  mastoid  cells, 
441 ;  technique  of,  391. 

Treves.  Diverticula  of  intestine,  536;  epitheli- 
oma of  intestine,  536;  intestinal  obstruction, 
533,  535 ;  operative  treatment  of  peritonitis, 
578 ;  stricture  of  intestine,  537. 

Trichiasis,  407. 

Trigonocephalus,  79. 

Trochanter  of  femur,  fracture  of,  313. 

Trommer.     Test  for  sugar  in  urine,  643. 

True  aneurism,  302. 

Truss  for  hernia,  558. 

Tubercular  syphilide,  731. 

Tuberculosis  of  bone,  376 ;  of  epididymis,  747 ; 
of  hip-joint,  354 ;  of  joints,  353  ;  of  lymphatic 
glands  of  neck,  494 ;  of  mammary  gland,  517 ; 
of  prostate  gland,  674  ;  of  spine,  787  ;  of  testi- 
cle, 747;  of  thyroid  gland,  494;  of  urethra, 
706;  of  vesiculiB  seminales,  744;  of  vulva, 
757. 

Tubular  adenoma,  850 ;  epithelioma,  841. 

Tufnell.     Aneurism,  206,  237. 

Tumefaction  in  inflammation,  55. 

Tumors,  837 ;  cirsoid,  190 ;  cutaneous  arterial, 
190;  capillary,  190,  195;  venous,  190,  195 
cystic,  of  ovary,  774,  vide  cyst ;  erectile,  195 
of  antrum  of  Highmore,  471 ;  of  the  bladder. 
639;  of  frontal  sinus,  445;  of  head,  382;  of 
larynx,  505  ;  of  mammary  gland,  515  ;  of  neck, 
493 ;  of  nose,  443 ;  of  oesophagus,  509 ;  of 
parotid  gland,  468;  of  pharynx,  507;  of  the 
prostate,  674;  of  the  scalp,  382;  of  urethra, 
.  706;  vascular,  190;  excision  of,  192;  ligation 
of,  carotid  for,  192 ;  venous,  190 ;  venous  cu- 
taneous, 195. 

Tunica  funiculi,  736. 

Tunica  vaginalis,  735 ;  affected  in  epididymitis, 
744 ;  hiematoma  of,  735 ;  hydrocele  of,  735. 

Turbinated  bones,  446. 

Twisting  of  intestines,  534. 

Tympanitis,  578. 

Typhlitis,  579. 

Ulcer,  99 ;  herpetic,  412 ;  of  the  prepuce,  713 ; 
of  the  anus,  600 ;  of  the  cornea,  413 ;  of  the 


leg,  200 ;  of  the  lips,  453 ;  of  the  penis,  713 ; 
of  the  tongue,  483  ;  of  the  vulva,  757 ;  phage- 
denic, 714 ;  serpiginous,  of  cornea,  413 ;  sim- 
ple, 713,  716;  specific,  717;  syphOitic,  717, 
719  ;  tertiary,  of  the  skin,  733. 

UUman.  Ligation  of  carotid  for  vascular  tu- 
mor, 193. 

Ulna,  dislocation  of,  at  elbow,  334 ;  fracture,  399. 

Ulna  and  radius,  dislocations  of,  335. 

Ulnar  artery,  aneurism  of,  227 ;  ligation  of,  362 : 
nerve,  injury  to,  from  dislocations,  335. 

Umbilical  hernia,  554 ;  diagnosis  and  treatment, 
572. 

Umbrella  compress,  662 ;  probang,  508. 

Undescended  testicle,  750. 

Ununited  fractures,  324. 

Upper  extremity,  deformities  of,  826. 

Ura;mia,  623. 

Urea,  641. 

Ureteritis,  630. 

Ureters,  affections  of,  627 ;  compression,  637. 

Urethra,  676 ;  carcinoma,  706  ;  cocaine  anjesthe- 
siafor,  689;  fibroma,  706;  fistule,  702;  rectal, 
703 ;  foreign  bodies  in,  700 ;  malformations, 
705 ;  neoplasms,  706 ;  papilloma,  706 ;  sti-icture 
of,  677,  678 ;  of  membranous,  696 ;  treatment 
of,  693. 

Urethral  forceps,  701 ;  sounds,  698 ;  speculum, 
706. 

Urethritis,  676 ;  a  cause  of  pyelitis,  630 ;  chronic, 
686 ;  chronic  follicular,  687  ;  non-specific,  679 ; 
simple,  685 ;  specific,  676 ;  treatment,  679. 

Urethrotome,  Banks's,  691 ;  Otis's,  693, 

Urethrotomy,  693  ;  external,  697 ;  internal,  693  ; 
modified,  696. 

Uric  calculus,  646. 

Urinal.  628,  639. 

Urinalysis,  641. 

Urinary  fistula,  703 ;  rectal,  703. 

Urine,  640 ;  examinations  of,  641 ;  incontinence, 
638 ;  infiltration,  630 ;  physiology,  641 ;  reten- 
tion, 635;  suppression  of,  619,  634,  635. 

Uterus,  Ciesarean  section,  766 ;  carcinoma,  765 ; 
cei'vix  of,  amputation  of  the,  764 ;  excision, 
764 ;  laceration,  763 ;  excision,  abdominal,  766 ; 
of  pregnant,  768;  vaginal,  765;  extirpation, 
765;  prolapse,  760. 

Uvula,  affections  of,  478 ;  excision,  478. 

Vaccination  for  angioma,  197. 

Vagina,  absence  of,  756 ;   atresia,   759 ;  hernia 

into,  574  ;  stricture,  759. 
Vaginal  hysterectomy,  765. 
Vaginismus,  759. 
Vaginitis,  758. 
Valgum,  genu,  804. 
Valgus,  talipes,  819. 

Valsalva.    Teatment  for  aneurism,  305,  306,  212. 
Van  Arsdale.    Action  of  iodoform  on  ptomaines, 

5 ;  subluxation  of  the  head  of  the  radius,  335. 


A  TEXT-BOOK   ON   SURGERY. 


Van  Buren.  Curvature  of  steel  sounds,  699 ; 
cupped  sound,  673 ;  debris  syringe,  661 ;  he- 
maturia, method  of  determining  source  of, 
644 ;  urethral  scoop,  701. 

Vance.     Corset,  785. 

Varicocele,  198,  740;  diagnosis,  556,  736,  738; 
radical  cure,  741,  743  ;  treatment,  741. 

Varicose  aneurism.  332:  veins,  198;  ulcus,  99. 

Varicosities  of  lymphatic  vessels,  165. 

Varix,  198 ;  aneurismal,  203,  233 ;  arterial,  190 ; 
treatment,  200. 

Varum,  genu,  809. 

Varus,  talipes,  814. 

Vascular  formation  in  V7ounds,  69 ;  system,  sur- 
gery of  the,  163 ;  tumors,  excision  of,  193 ; 
ligation  of  carotid  for,  193. 

Vas  deferens,  744. 

Vaseline,  iodoform,  95. 

Vein,  internal  jugular,  ligation  of,  337,  353; 
wounds  of,  in  ligation  of  carotid,  238. 

Veins,  haemorrhage  from,  71. 

Velpeau.  Bandage  for  dislocation  of  clavicle, 
337;  fracture  of  clavicle,  394,  837;  vascular 
tumor,  193. 

Venesection,  57 ;  in  aneurism,  305 ;  in  inflamma- 
tion, 57. 

Venom,  scorpion,  80 ;  snake,  78 ;  tarantula,  81 ; 
toad,  80. 

Venom-albumen,  79. 

Venom-globulin,  79. 

Venom-pepton,  79. 

Venous  hfemorrhage,  71 ;  occlusion  in  gangrene, 
101  ;  tumors,  cutaneous,  190 ;  varix,  198. 

Ventral  hernia,  554;  treatment,  573. 

Verneuil.  Case  of  aneurism,  327 ;  tapping  of 
eohinocoecus  sac  of  liver,  585 ;  varix,  189. 

Vertebrae,  dislocation  of  the,  350;  fractures. 
305. 

Vertebral  artery,  355;  aneurism  of,  228;  diag- 
nosis, 230 ;  ligation,  259. 

Vesico-vaginal  fistula,  761. 

Vesiculae  seminales,  743  ;  inflammation  of,  744 ; 
wounds,  743. 

Vesicular  syphilids,  731. 

Vichy  water  in  cystitis,  633. 

Villardebo.     Case  of  aneurism,  318. 

Villous  polypus  of  rectum,  607 ;  tumors  of  blad- 
der, 639. 

Violin-strings  as  ligatures,  1. 

Vipera,  79. 

Virchow.    Phlebitis,  167 ;  tumors,  837. 

Visceral  syphilis,  184. 

Vision  tests,  431  et  seq. 

Vitreous  humor,  433 ;  foreign  bodies  in,  433. 

Volkmann.  Foot-rest  for  fracture  of  femur, 
310 ;  operation  for  hydrocele,  739 ;  scoop,  38. 

Volvulus,  534. 

Vulva,  abscess  of,  751 ;  affections,  751 ;  chan- 
croids, 757 ;  contusions,  751 ;  epithelioma,  751 ; 
haematoma,  751 ;  lupus,  757 ;  papilloma,  757 ; 


pruritus,  758 ;  rupture  of  posterior  parts,  753 ; 
syphilis,  757;  tuberculosis,  757;  ulcers,  757; 
wounds,  751. 
Vulvitis,  757. 

Wardrop.  Case  of  aneurism,  218 ;  case  of  erec- 
tile tumor,  191  ;  operation  for  aneurism, 
207. 

Wardwell.    Calcification  of  arteries,  179. 

Warren.  Case  of  aneurism,  334 ;  vascular  tu- 
mors, 196 ;  excision  of,  193 ;  ligation  of  ca- 
rotid for,  192. 

Wart,  849  ;  of  head,  383. 

Wasp-sting,  81. 

Wassiliefl.    Glanders,  83. 

Water,  boiled,  for  irrigation  of  wounds,  74 ; 
pure,  for  continuous  irrigation  in  amputa- 
tions, 130. 

Watson.     Case  of  aneurism,  339. 

Weber.     Case  of  syphilitic  arteritis,  181. 

Weber,  0.  Coagulation  after  arterial  ligation. 
189. 

Web-finger,  839. 

Webster.    Hordeolum,  399 ;  pannus,  413. 

Web-toe,  833. 

Weigert.  Calcification  of  arteries,  180:  coagu- 
lation necrosis,  180 ;  inflammation,  67. 

Weir.  Case  of  aneurism,  317;  case  of  osteoto- 
my of  femur,  804 :  spray-machine,  4. 

Weitzer.     Excision  of  vascular  tumor,  193. 

Wells.  Fenestrated  forceps,  656 ;  sac-forceps, 
777. 

Wens,  383,  850. 

Whisky  after  burns,  93 ;  for  serpent-venom,  80. 

White.  Arteritis  syphilitica,  183  ;  phlebitis. 
169. 

Whitehead.  Operation  for  haemorrhoids,  612, 
613,  615. 

White  lead  for  bui'ns,  93. 

Whitlow,  834. 

Wild.    Bar  speculum,  439. 

Wire,  ecraseur,  443 ;  in  the  treatment  of  aneu- 
rism, 210. 

Wolf-bite,  81. 

Wolff.     Cradle,  784. 

Wolfler.    Gastro-enterostomy,  538,  529. 

Wolverton.     Tooth-forceps,  477. 

Wood.  Open  method  of  treating  for  amputa- 
tions, 119. 

Wood-wool  as  an  absorbent  dressing,  9. 

Wounds,  68  ;  adhesive  plaster  in,  76  ;  contused, 
68  ;  dissection,  84 ;  dressings,  84  ;  granulating 
process  in,  69  ;  gunshot,  90,  vide  gunshot; 
healing  of,  69 ;  incised,  68 ;  insect,  68,  81 ; 
lacerated,  68 ;  of  ear,  439 ;  of  eye,  396 ;  modes 
of  dressing,  53  ;  of  the  abdominal  walls,  586 ; 
of  the  abdominal  organs,  587 ;  of  the  arteries, 
304 ;  of  the  bladder,  629  ;  of  the  bowels,  587 ; 
of  the  chest,  523 ;  of  the  cornea,  411 ;  of  the 
face,  395 ;  of  the  heart,  524 ;   of  the  kidney. 


INDEX. 


887 


619  ;  of  the  lips,  452 ;  of  the  lymphatic  vessels, 
164 ;  of  the  neck,  491  ;  of  the  oesophagus,  491 ; 
of  the  penis,  707  ;  of  the  scalp,  386  ;  of  the 
scrotum,  733  ;  of  the  skull,  387  ;  of  the  testicle, 
745  ;  of  the  tongue,  483 ;  of  the  vesciulK  semi- 
nales,  743;  of  the  vulva,  751;  poisoned,  78; 
by  dissection,  84 ;  by  glanders,  83 ;  by  insects, 
68,  81 ;  by  malignant  pustule,  83  ;  by  rabid 
animals,  81 ;  by  serpents,  78 ;  punctured,  68 ; 
serpent,  78,  79 ;  sutures  in,  76 ;  of  scalp,  386 ; 
treatment,  70. 


Wrist,  amputation  at,  126;    dislocations,  337; 

exsection,  368,  379 ;  synovitis,  367. 
Wry-neck,  779. 
Wutzer.     Rhinoplasty,  450. 

Xanthio  calculus,  647. 
Xerosis,  411. 

Zinc,  acetate  of,  in  gonorrhoea,  681,  685  ;  chloride 

of,  as  an  antiseptic,  3. 
Zygomatic  process,  fracture  of  the,  289. 


N 


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